Minimising Restrictive Practices: Restraint

CPD
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Published: 09 August 2020

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).

Also read: Minimising Restrictive Practices: Seclusion.

What is Restraint?

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

depressed older woman
Restraint may further exacerbate the client’s trauma or inflict physical or emotional harm.

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

Physical restraint The act of physically immobilising the client through bodily force, or the removal of the client’s mobility aids.
Mechanical restraint The use of devices to restrict the client’s movement. These may include:
  • Belts;
  • Harnesses;
  • Sheets;
  • Straps;
  • Bed rails;
  • Lap belts;
  • Restraining chairs;
  • Table overlays;
  • Hand mitts; and
  • Vests.
Mechanical restraint does not include medical or surgical devices used for treatment (e.g. splint) or devices used for transporting clients.
Chemical restraint 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?

(ACSQHC 2019; PSEP 2017; VIC DoH 2018; RANZCP 2016)

posey restraints
Mechnical restraint is the use of devices to restrict the client’s movement.

Restraint in the National Safety and Quality Health Service Standards

Restraint is outlined in Action 5.35 of the National Safety and Quality Health Service Standards, under Standard 5: Comprehensive Care.

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.

(ACSQHC 2019)

Impacts of Restraint on the Client

Restraint can have a variety of severe, adverse consequences on the client.

Physical consequences Emotional consequences Social consequences Other consequences
  • Cuts and bruising
  • Strains and sprains
  • Pressure injury
  • Incontinence
  • Loss of muscle strength
  • Falls
  • Pain
  • Poor nutrition
  • Memory issues
  • Neuropathy
  • Mobility issues
  • Thrombosis
  • Blunt trauma
  • Acute dystonia
  • Acidosis
  • Rhabdomyolysis
  • Respiratory distress
  • Seizures
  • Cardiac issues
  • Asphyxia
  • Malignant syndrome
  • Death
  • 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
  • Confusion
  • Despair and hopelessness
  • Fear of readmission
  • Loss of trust between clients, staff and families
  • Social isolation
  • Shame
  • Negative stigma
  • Decreased self-esteem
  • Violation of human rights
  • Hindered recovery
  • 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.

Preventing Restraint

nurse practising empathetic listening with a client

There are three main ways you can minimise the need for restraint and other restrictive practices:

  1. Provide a respectful and welcoming service environment to ensure the client feels safe and comfortable.
  2. Identify and address behavioural changes before they escalate.
  3. 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:
    • Cognitive assessment;
    • Medical history;
    • Responsive behaviours (for patients with dementia);
    • The client’s routines, preferences and values;
    • Pain assessment;
    • Communication ability;
    • Delirium;
    • Medications;
    • Mental state;
    • Falls risk;
    • Psychosocial needs; and
    • Physical environment.
  • Refer the client to other services (e.g. general practitioner, physiotherapist) if deemed necessary.
  • Assess the client and the interventions that have been decided on an ongoing basis.
  • Involve the client and their family in the process of developing and implementing strategies.
  • Ensure staff are adequately trained in the ethics of restraint and possible alternatives.
  • Recognise situations that may cause clients to become distressed, anxious or aggressive.
  • Consider staffing residents one-on-one to ensure safety and supervision is increased until their underlying condition is identified and treated appropriately.

(VIC DoH 2018; QLD DoH 2016)

Providing a Respectful and Welcoming Service Environment

The following are some practical suggestions for caring for clients in a way that will help reduce challenging behaviours.

  • Ensure you deliver trauma-informed care that takes into account the client’s past traumatic experiences. Make sure they feel welcome and provide them with options so that they do not feel trapped.
  • Engage with the client and develop a therapeutic relationship with them.
  • Always deliver person-centred care.
  • Be polite and respectful, and practice empathetic listening.
  • Meet the client’s immediate needs.
  • When speaking to a client, be calm, introduce yourself, use their preferred name and provide verbal reassurance.
  • Practice effective and empathetic communication; validate the client’s concerns.
  • Provide the client with access to a range of meaningful activities they can choose from.
  • Align the client’s routine with what they are used to (e.g. shower and sleeping patterns).
  • Respect the client’s communication needs.
  • Use non-threatening behaviour and body language.
  • Do not invade the client’s personal space.
  • Inform the client in advance before you do anything.
  • Consider the client’s values and preferences.
  • Give the resident capacity to make choices or suggest alternatives.
  • Apologise if the client is upset (if reasonable).

(SA DoH 2015; VIC DoH 2018)

Identifying and Addressing Behavioural Changes

This involves recognising anxiety, which is the first sign of behavioural change, and addressing the client’s distress. If the situation escalates, you may need to use de-escalation strategies.

Read: Minimising Restrictive Practices: Seclusion

Reducing Falls Risk

The following strategies may be implemented to reduce the risk of falls so that restraint is not necessary:

  • Use equipment such as low beds, non-slip mats and hip protectors;
  • Ensure the service environment is secure, well-lit and safe for wandering; and
  • Address health issues such as mental health conditions, sensory loss, poor balance or unstable blood pressure.

(My Aged Care 2016)

Applying Restraint

older client with hand restraint
Restraint must only be performed by appropriately-trained staff members.

In the event that there is no other option but to use restraint, it is essential to refer to your state or territory’s legislation when performing the procedure. As a general guideline:

  • Restraint must only be implemented by staff members who have been appropriately trained in this area.
  • Restraint will need to be authorised by the relevant party. This depends on your state or territory.
  • Most states and territories require certain parties to be notified in the event of restraint.
  • Restraint should only occur for the minimum amount of time necessary. There may be time limits and extension provisions depending on your state or territory.
  • Take into account the patient’s individual risk factors, including their physical and cognitive state.
  • Take into account whether the patient is at risk of incurring significant trauma as a result of restraint (due to age, history of trauma or detention etc).
  • An appropriately-trained team of five to seven staff should be involved in physical restraint, with a maximum of five people physically contributing (more than five people may result in injury).
  • During mechanical restraint the client should always be in the supine position with the head of the bed raised.
  • Observe the client for signs of distress.
  • Only use the minimum amount of force necessary.
  • Always monitor the client’s breathing, airway, consciousness and body alignment.
  • Never place direct pressure onto the client’s neck, thorax, back or pelvis.
  • Stop the restraint as soon as it is no longer required.
  • Debrief the client after the incident.

(RANZCP 2017; SA DoH 2015; ACSQHC 2019; QLD DoH 2016)

Conclusion

Restraint and other restrictive practices are interventions that should only be used as a last resort in the event of a behavioural emergency.

Remember that these practices are highly distressing for the client and may cause or exacerbate trauma. The goal is to minimise and hopefully prevent restrictive practices as much as possible.

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

Additional Resources


References

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