Restraint is an ethically, legally and clinically harmful practice that violates a client’s fundamental human rights and may lead to poor outcomes (VIC DoH 2018).
As much as possible, healthcare services should aim to create and maintain a restraint-free environment. This is the recommended standard of care and will prevent clients from suffering unnecessary harm and trauma (VIC DoH 2016).
Restraint is the practice of intentionally restricting a client’s movement or behaviour to prevent harm or danger to the client, staff or other people (ACSQHC 20219; My Aged Care 2016).
Restraint, along with seclusion, are types of restrictive practice used for behavioural emergencies in various healthcare settings.
When is Restraint Used?
Restrictive practices are used as a last resort intervention in the event of a behavioural emergency. They may further exacerbate the client’s trauma or inflict physical or emotional harm, posing a profound risk to their safety and wellbeing and even increasing the risk of death. Furthermore, these interventions are not known to alter the client’s behaviour in the long-term (PSEP 2017; VIC DoH 2018).
Remember that restraint is not a therapeutic intervention and should never be treated as such (Melbourne Social Equity Institute 2014).
For these reasons, restraint must only be used if there are no other suitable options remaining, and for the shortest amount of time possible (VIC DoH 2016).
These situations may include:
Where there is a significant safety risk to the patient, staff or other people, and the risks of not restraining outweigh the risks of restraining.
Where there is a significant risk of persistent property damage.
Where the client requires essential medication or treatment immediately, and there is no other way to administer it.
Where the client is under care and control or an Inpatient Treatment Order (ITO) and needs to be prevented from leaving the premises.
(SA DoH 2015; RANZCP 2016)
Note: The situations wherein restraint is permitted differ slightly between states and territories. Always refer to your state or territory’s legislation when considering restraint. In all states and territories, restraint is strictly a last resort and is only to be used if there are no other options.
Restraint in Aged Care
In aged care settings, restraint has been cited as a means of preventing falls, wandering or absconding in clients with poor health, dementia, mental health conditions or physical disability. However, restraint in aged care has been linked to poor outcomes and is less regulated than in the mental health sector (ACSQHC 20219; My Aged Care 2016; VIC DoH 2016).
It has been suggested that restraint may actually increase the risk of falls, as it can cause muscle deterioration if used for a prolonged period of time (SA DoH 2015).
When Should Restraint Not be Used?
It is important to limit the use of restraint as much as possible, with the exception of emergency situations. Restraint should never be used:
As a therapeutic intervention;
In response to boredom;
In response to illness;
In response to anxiety or distress;
To compensate for staff shortages;
As a substitute for less restrictive alternatives;
As punishment, threat or discipline; or
For the convenience of staff.
(VIC DoH 2016; Melbourne Social Equity Institute 2014; QLD DoH 2016)
Types of Restraint
The act of physically immobilising the client through bodily force, or the removal of the client’s mobility aids.
The use of devices to restrict the client’s movement. These may include:
Hand mitts; and
Mechanical restraint does not include medical or surgical devices used for treatment (e.g. splint) or devices used for transporting clients.
The use of medication to control the client’s behaviour. Chemical restraint is difficult to define and somewhat legally ambiguous, as it is difficult to tell whether medications are being used for treatment purposes or to restrict movement. More information can be found in What is Chemical Restraint and is it Legal?
This action aims to minimise the use of restraint in healthcare, and consequently, the harm incurred by clients. Providers are required to meet the following guidelines:
The use of restraint is minimised and eliminated if possible;
Restraint is used in accordance to legislation; and
Any use of restraint is reported to the governing body.
Impacts of Restraint on the Client
Restraint can have a variety of severe, adverse consequences on the client.
Cuts and bruising
Strains and sprains
Loss of muscle strength
Post-traumatic stress disorder (estimated to affect between 25 and 47% of clients who have experienced a restrictive practice)
Loss of dignity
Mood swings (e.g. anger, depression, withdrawal)
Anxiety or depression
Despair and hopelessness
Fear of readmission
Loss of trust between clients, staff and families
Violation of human rights
Determent from voluntarily seeking healthcare services in the future
Distress for family members
(My Aged Care 2016; Chieze et al. 2019; PSEP 2017; Melbourne Social Equity Institute 2014; SA DoH 2015)
Restraint in Australia
Restraint is governed by strict legislation in Australia. The practice is outlined in state and territory legislation with different conditions. The legal definition of restraint, the situations in which it can be used and other provisions (such as whether chemical restraint is permitted) depend on your state or territory of practice. You can find an overview of these differences on the RANZCP’s website.
Any restrictive practice must be performed under the specified acceptable situations in your state or territory’s legislation.
In the year 2018-2019, there were 18 690 physical restraint events and 991 mechanical restraint events recorded in Australia (AIHW 2020).
According to the RANZCP (2016), barriers to decreasing the prevalence of restraint include:
Lack of identified good practice and clinical standards;
Lack of quality improvement and clinical review;
Inappropriate use of restraint (e.g. as a threat);
Lack of staff knowledge, education and training;
Lack of knowledge in de-escalating early warning signs; and
Lack of resources and inadequate facilities.
There are three main ways you can minimise the need for restraint and other restrictive practices:
Provide a respectful and welcoming service environment to ensure the client feels safe and comfortable.
Identify and address behavioural changes before they escalate.
Reduce falls risk through alternative safety measures before the need for restraint arises.
(VIC DoH 2018)
In general, health service organisations should:
Recognise behavioural changes when they occur and identify clients who may be at risk of requiring restraint.
Conduct a comprehensive assessment of each client and develop an individualised plan if any risk factors are identified. The assessment should include:
Responsive behaviours (for patients with dementia);