Use of restraint in health care settings

Nurses and other health practitioners must be conscious of the impact of the use of restraint on the rights and dignity of health care consumers, whatever the setting.  Different policies, guidelines and regulations apply depending on the setting.  However, the guiding principles for the use of restraint have been identified in a recent Australian Law Reform Commission report. The 2017 Elder Abuse—A National Legal Response report recommended that restraint only be used:

1. as a last resort, after alternative strategies have been considered, to prevent serious physical harm
2. to the extent necessary and proportionate to the risk of harm
3. with the approval of a person authorised by statute to make this decision
4. as prescribed by a person’s behaviour support plan
5. when subject to regular review.

Aged care regulation

In anticipation of concerns about restraint being examined by the current aged care royal commission, the Commonwealth Government’s Quality of Care Amendment (Minimising the Use of Restraints) Principles 2019 amended the Quality of Care Principles 2014 which came into effect from 1 July 2019.  The aim of the amendment is to promote a restraint-free environment in aged care facilities. The amendment gives aged care providers new responsibilities to minimise the use of restraint.

The amended Quality of Care Principles 2014 deal with two types of restraint – physical and chemical. Restraint is described as any practice, device or action that interferes with the consumer’s ability to make a decision or restricts a consumer’s free movement.

1. Chemical restraint is the use of medication for the purpose of influencing a consumer’s behaviour (other than when the medication is used to treat a diagnosed mental disorder or physical illness or condition).
2. Physical restraint includes any restraint, other than chemical restraint.

Physical restraint

Four conditions must be satisfied before physical restraint is used:

1. assessment by a medical practitioner, nurse practitioner or registered nurse who has day-to-day knowledge of the consumer
2. alternatives to the use of restraint have been used to the extent possible
3. least restrictive form of restraint possible is used
4. informed consent of the consumer or consumer’s representative (except emergencies).

Chemical restraint

Three conditions must be satisfied before chemical restraint is used:

1. assessment by a medical practitioner or nurse practitioner, with the same practitioner being responsible for prescribing the medication as chemical restraint
2. the practitioner’s decision to use the restraint must be documented
3. the consumer or their representative must be informed of the decision to use chemical restraint in a way that they can understand. There must be an opportunity provided to discuss any concerns.

Informed consent is not required prior to restraining a consumer in an emergency.  However, the consumer’s representative must be informed as soon as practicable after the restraint starts and the representative may decline to consent or withdraw the consent at any time.

Use of restraint in other healthcare settings

While the Quality of Care Principles 2014 apply to Commonwealth funded aged care facilities, other regulations apply in different settings.  In designated mental health services, the Mental Health Act 2014 regulates the use of bodily restraint and seclusion.  In other acute care settings such as public and private hospitals, the Department of Health and Human Services publishes policies and guidelines, which are usually reflected in hospital policies.

Failure to adhere to policies/guidelines/regulations about restraint

When health practitioners employ any practice, device or action that interferes with the consumer’s ability to make a decision or restricts a consumer’s free movement, they must familiarise themselves with the relevant instrument governing the use of such restraint in that setting.  Failure to do so exposes the practitioner to civil claims as well as criminal charges such as false imprisonment.  Practitioners failing to adhere to policies/guidelines/regulations may also find themselves under the scrutiny of an AHPRA investigation into their conduct.

Conclusion

It is essential that health practitioners familiarise themselves with the policies/guidelines/regulations applicable to the healthcare setting in which they practise before intervening to restrain a consumer.  Inappropriate use of restraint not only offends the consumer’s human rights and dignity, it exposes the practitioner to civil and even criminal sanction.