Minimising Restrictive Practices in Aged Care: Rules and Regulations

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Published: 16 September 2021

This article is intended to be read alongside Alternative Strategies to Restrictive Practices in Aged Care.

Restrictive practices are ethical, legal and clinical violations of fundamental human rights that may lead to poor care outcomes (VIC DoH 2018).

As much as possible, aged care services should aim to create and maintain a restrictive practice-free environment. This is the recommended standard of care and will prevent residents from suffering unnecessary harm and trauma (VIC DoH 2016).

As of 1 July 2021, the Aged Care Act 1997 has been updated with new amendments aiming to further regulate and strengthen restrictive practice requirements for residential aged care providers (DoH 2021a).

Note: Updated legislation now uses the term ‘restrictive practices’ instead of the previously-used ‘restraint’.

Restrictive practices are detailed under Standard 3. Personal Care and Clinical Care and Standard 8. Organisational Governance of the Aged Care Quality Standards.

What is a Restrictive Practice?

mechanical restraint bedrails

The Aged Care Act defines a restrictive practice as ‘any practice or intervention that has the effect of restricting the rights or freedom of movement of the care recipient’.

Restrictive practices are most commonly used in aged care in order to:

(RCACQS 2019; Carer Gateway 2021)

There are five types of restrictive practices:

Seclusion Confining a resident in a room or physical space by themselves (at any hour of the day or night) and preventing them from leaving voluntarily, or implying that they cannot leave voluntarily. Examples include:
  • Locking a resident in a room
  • Imposing a ‘time out’.
Chemical restraint Using medications or chemical substances to influence a resident’s behaviour. This does not include medications that have been prescribed by a medical practitioner to treat a mental or physical condition.
Mechanical restraint Using devices such as lap belts, bed rails and restrictive clothing to restrict a resident’s movement for the purpose of influencing their behaviour. This does not include devices used for therapeutic or non-behavioural purposes, e.g. a wheelchair.
Physical restraint Using physical force to prevent, restrict or subdue the movement of a resident’s body for the purpose of influencing their behaviour. Examples include:
  • Physically holding a resident in a certain position
  • Pinning a resident down
  • Physically moving a resident to prevent them from moving in the direction they wish to go.
Environmental restraint Restricting a resident’s free access to environments, items or activities. Examples include:
  • Putting wanted or needed items out of reach
  • Restricting access to certain activities.

(ACQSC 2021a)

For more clarification on what is and isn’t considered a restrictive practice, view the following resource from the Aged Care Quality and Safety Commission:

When are Restrictive Practices Permitted?

Restrictive practices must only be used as a last resort to protect the resident, yourself or others from harm. They must be used in the least-restrictive form possible, and only after considering the likely impact on the resident (ACQSC 2021a).

Under the Aged Care Act 1997 and the Quality of Care Principles 2014, there are now strict requirements that must be met in order for a restrictive practice to be used lawfully in a residential aged care setting:

  • The restrictive practice must be used as a last resort to prevent harm, after considering the likely impact on the resident
  • The restrictive practice must be used in the least-restrictive form, for the shortest amount of time possible
  • The restrictive practice must be proportionate to the perceived risk of harm
  • Alternative strategies to restrictive practices must be attempted first; these must be documented, along with why they have not been successful
  • The restrictive practice must be deemed as necessary by an approved health practitioner after undertaking an assessment of the resident; this must be documented
    • In the case of chemical restraint, the medicine used must have been prescribed by an appropriately qualified health practitioner who has documented the reason for this prescription
  • Informed consent must be given from the resident or their restrictive practices substitute decision-maker
  • The use of restrictive practices must be regularly reviewed and removed as soon as possible
  • When the restrictive practice is being used, the resident must be regularly monitored for distress, harm, adverse events, changes in wellbeing and ability to perform daily living activities
  • From 1 September 2021, providers must have a Behaviour Support Plan (BSP) in place for all residents who:
    • Display changed behaviours
    • Are being assessed to see if restrictive practices may be needed
    • Are experiencing a restrictive practice
  • The restrictive practice must be used in accordance with the Charter of Aged Care Rights, the Aged Care Quality Standards, relevant state or territory legislation and the resident’s BSP.

(DoH 2021a, b; ACQSC 2021a, b)

Note: Restrictive practices 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
  • For the convenience of staff.

(VIC DoH 2016; Melbourne Social Equity Institute 2014; QLD DoH 2016)

Emergency Use of Restrictive Practices

In rare cases, a serious and unexpected situation may arise where a restrictive practice is needed in order to protect a resident or another person from immediate harm (ACQSC 2021a).

In these emergencies, restrictive practices may be used and with exemption from certain requirements such as consent. However, the resident’s restrictive practices substitute decision-maker must be informed as soon as possible once the restrictive practice has commenced (ACQSC 2021a).

The following must also be documented in the resident’s care and services plan:

  • The behaviour that required the emergency use of a restrictive practice
  • Any alternatives to restrictive practices that were considered or used
  • The reasons why the restrictive practice was necessary
  • The care that will be provided to the resident in order to address this behaviour
  • A record that the resident’s restrictive practices substitute decision-maker was informed about the use of the restrictive practice
  • Any relevant assessments, information and decisions
  • Any additional advice or support that is needed.

(ACQSC 2021a)

Why are Restrictive Practices Harmful?

older woman sitting sadly

Restrictive practices may exacerbate a resident’s trauma or inflict physical or emotional harm, posing a profound risk to their safety and wellbeing and even increasing their risk of death. Furthermore, these interventions are not known to alter the resident’s behaviour in the long-term (PSEP 2017; VIC DoH 2018).

Remember that restrictive practices are not therapeutic interventions and should never be treated as such (Melbourne Social Equity Institute 2014).

The following table illustrates just some of the potential harms of restrictive practices:

Seclusion
  • Preventable injury or death
  • Psychological trauma
  • Feelings of distress, powerlessness, humiliation, abandonment or rejection
Chemical restraint
  • Sedation, gait disturbance or increased falls risk
  • Urinary tract infection or incontinence
  • Cognitive impairment or confusion
  • Constipation, potentially leading to fecal impaction or bowel obstruction
  • Extrapyramidal (movement-related) side effects
  • Respiratory complications, stroke, arrhythmia or death
Mechanical restraint
  • Distress
  • Physical injury
  • Suffocation or choking
  • Reduced ability to perform daily living activities
Physical restraint
  • Fear, shame, loss of dignity, agitation, depression or decreased cognitive performance
  • Bruising, skin injury, pressure injury, respiratory complications, incontinence, constipation, malnutrition, reduced mobility, increased dependence or reduced muscle strength
  • Serious injury or death
Environmental restraint
  • Reduced rights and freedoms, including for others who are receiving care (e.g. a locked door affects all care recipients, not just the resident who the door has been locked for)

(RCACQS 2019; NDIS 2020)

Conclusion

Restrictive practices are interventions that should only be used as a last resort.

Remember that these practices are highly distressing for the resident and may cause or exacerbate trauma. As someone caring for these residents, your goal should be to minimise and hopefully prevent restrictive practices as much as possible.

Always refer to your state or territory’s legislation, as well as your organisation’s policies and procedures.

Additional Resources


References

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