Restrictive Practices

Katie Nesbitt
Katie Nesbitt
Last updated 
What are restrictive practices, and when their use is authorised

Overview

Introduction
This policy is about regulated restrictive practices. A restrictive practice is defined as any practice or intervention that restricts the rights or freedom of movement of a person, with the primary purpose of protecting the person or others from harm.

Prohibited Practices
Any practice or action that may be experienced by a person as noxious, unpleasant or painful. Types of prohibited practices include aversive, consequence-driven, exclusion, and psychosocial restraints.

Prohibited practices include but are not limited to:
  • any form of corporal punishment (for example, smacking or hitting)
  • any punishment intended to humiliate or frighten a person
  • any punishment that involves immobilising a person with chemical or physical restraint, including supine and prone restraint holds
  • force-feeding or depriving a person of food
  • use of medication to control or restrain a person without a behaviour support plan, proper medical authorisation or legal consent
  • use of punishing techniques, such as putting a person in a hot or cold bath, putting spice in their food, or squirting the liquid on their face or body
  • overcorrection, where the punishment is out of proportion to the behaviour (for example, making a person clean an entire room because they tipped their meal on the floor)
  • confinement or containment of a child or young person (anyone under 18 years of age), such as forcing them to remain in a locked room or other places that they can’t leave
  • punishment that involves threats to withhold family contact or change any part of a person’s lifestyle plan
  • denying access to basic needs or supports
  • unethical practices, such as rewarding a person with cigarettes or alcohol
  • any other act or failure to act that is an offence under federal, state or territory laws.
Prohibited practices are practices that must never be used. They may unlawful or unethical. Any prohibited practice may be a criminal offence or civil wrongdoing. Any use of a prohibited practice is a reportable incident under the NDIS (Incident Management and Reportable Incidents) Rules 2018 (Cth).

Regulated Restrictive Practices 
Only regulated restrictive practices are allowed and then only with strict controls. Regulated restrictive practices include:
  • Chemical Restraint 
    • The use of medication or chemical substances for the primary purpose of influencing a person’s behaviour or movement. It does not include the use of medication prescribed by a medical practitioner for treating a diagnosed mental illness or physical condition.
  • Environmental Restraints 
    • Any restriction to a person’s free access to all parts of their environment. For example: 
      • locking cupboards and refrigerators 
      • taking away things people like 
      • stopping the person from going to places they enjoy.
  • Mechanical Restraint 
    • The use of a device to prevent, restrict or subdue a person’s movement for the primary purpose of influencing their behaviour. It does not include the use of devices for therapeutic or non-behavioural purposes. For example, it may include using a device to assist a person with functional activities as part of occupational therapy or to allow for safe transportation.
  • Physical Restraint 
    • The sustained or prolonged use or action of physical force to prevent, restrict or subdue movement of a person’s body, or part of their body, for the primary purpose of influencing a person’s behaviour.
  • Seclusion 
    • Sole confinement of a person in a room or physical space at any hour of the day or night where the voluntary exit is prevented, impeded or not facilitated.
Applies
  • to all services provided to HWH clients with a positive behaviour support plan that includes the use of a regulated restrictive practice
  • when a prohibited practice or unauthorised regulated practice is used
  • to all HWH representatives, including key managers and home support workers
Related Items
  • NDIS (Quality Indicators) Guidelines 2018 (Cth) 
  • NDIS (Restrictive Practices and Behaviour Support) Rules 2018 (Cth)
  • Regulated restrictive practices with children and young people - Practice Guide

Policy

Restrictive Practice Principles
  • We support the reduction and elimination of the use of restrictive practices. Any use of restrictive practice will consider the client's cultural and communicative needs. We will only use restrictive practices:
    • as a last resort, and with proof, all other ways of evidence-based, person-centred and proactive strategies have been tried first
    • if the behaviour might harm the person or others
    • for the shortest time possible
    • in the least restrictive way possible
    • that is proportionate and justified
    • if the client or the client’s guardian has given consent
    • if the appropriate authorisation by state or territory bodies has been granted
    • if we have first understood why the client has complex behaviour and how the restrictive practice will affect the rights of the participant
    • if the practice is written in an NDIS lodged positive behaviour support plan developed by a positive behaviour practitioner or specialist in consultation with the client, the client’s family, support network and/or advocate.
  • We will be transparent and accountable for using restrictive practices through accurate record-keeping and reporting.
  • We will regularly review records to assess the success, need and application of restrictive practices.
Impact of Restrictive Practices
  • Research has demonstrated that restrictive practices do not effectively address underlying behavioural functions nor modify persistent concerning behaviour.
  • Research has also demonstrated that routine and ongoing restrictive practices on clients, client support networks and workers can be profoundly negative.
  • The use of the restrictive practice, whether on a single or ongoing occasion, according to the NDIS Quality and Safeguards Commission, can result in:
    • participants feeling a loss of dignity
    • reduced interpersonal relationships between participants and others
    • limited freedom and potential human rights violations
    • medication dependency
    • physiological and neurological changes
    • increased mental health illnesses
    • trauma and psychological distress, including post-traumatic stress disorder (PTSD) for participants, workers and support networks
    • secondary forms of concerning behaviours in response to the use of restrictive practices.
  • With this knowledge and understanding, we continuously monitor, evaluate and seek to reduce the use of restrictive practices with the goal of total restrictive practice use elimination.
Reduction and Elimination
We are committed to the reduction and elimination of restrictive practices and upholding the human rights of people with disability in line with the UN Convention on the Rights of Persons with Disabilities, NDIS Safeguarding Framework and the National Framework for Reducing and Eliminating the Use of Restrictive Practices in the Disability Service Sector. 

We are committed to achieving this by following the core strategies:

Person-Centred Focus
  • Including the perspectives and experiences of people with disability and their families, carers, guardians and advocates during restrictive practice incident debriefing, individualised positive behaviour support planning, staff education and training, and policy and practice development.
Leadership Towards Organisational Change
Making the goal of reducing restrictive practices a high priority and providing support to staff to achieve it.

Use of Data to Inform Practice
Mechanisms such as periodic review of positive behaviour support plans containing a restrictive practice, provider reporting on the use of restrictive practices, reporting client assessments and individual/positive behaviour support plans—should be used to assess whether restrictive practices are still needed and consider possible alternatives. Data is also vital to determine what factors effectively reduce or eliminate the use of restrictive practices, as well as highlight areas for workforce training and development.

Workforce Development
Essential needs include understanding positive behaviour support and functional behaviour assessment, skills for trauma-informed practice, risk assessment, de-escalation, and alternatives to restrictive practices.

Use Within Disability Services of Restraint and Seclusion Reduction Tools
Use evidence-based assessment tools, emergency management plans and other strategies integrated into each individual’s positive behaviour support plan. Changes to the therapeutic environment. Meaningful activities aimed at lifestyle improvement and increased engagement.

Debriefing and Practice Review
Regular reviews of the use of restrictive practices to identify areas for practice and systemic improvement. Suppose an unanticipated or emergency use of a restrictive practice occurs. In that case, an immediate debriefing should occur to ensure that everyone is safe, that satisfactory information is available to inform later structured debriefing, and that the client is safe and being appropriately monitored.

Client Assessment
  • We will assist in identifying clients with complex behaviour support needs and refer them to an NDIS-approved positive behaviour support client for assessment. 
  • A positive behaviour support practitioner, in consultation with the client, client's family, support network and/or advocate and the organisation, will be responsible for establishing a positive behaviour support plan which may include restrictive practices.
  • Restrictive practices in a client's positive behaviour support plan will have clear protocols for implementation and use. These practices will be reviewed at least every 12 months to reduce or eliminate the requirement of restrictive practices.
Authorising restrictive practice
Commonwealth, state and territory legislative and policy frameworks provide guidelines around the use of restrictive practices, including that the intervention is the least restrictive response available, is used only as a last resort, that the risk posed by the proposed intervention is in proportion to the risk of harm posed by the behaviour of concern and with the intent to reduce and eliminate the use of the restrictive practice.

The use of a restrictive practice will only be approved as part of a positive behaviour support plan. Clients or the client's guardian, the person responsible or substitute decision-maker, must consent to the proposed restrictive practices included in the positive behaviour support plan. We must also have the relevant state or territory approval to implement and use restrictive practices. The relevant approving authorities are detailed below.
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Record keeping
We will keep a record of the following:
  • restrictive practices that are ongoing (e.g. chemical restraint with a daily fixed dose)
  • restrictive practices that are ‘unscheduled’ (e.g. physical restraint, seclusion, chemical restraint prescribed on an ‘as-needed basis, also known as PRN medication)
  • occasions when the use of an unauthorised restrictive practice is defined as a serious incident—also reported as a serious incident.
The detail of the report on the use of regulated restrictive practices includes:
  • a description which includes: 
    • the impact on the client or others 
    • any injury to the clients or others 
    • whether the use was a reportable incident 
    • why it was used 
  • a description of the behaviour of the client that leads to its use
  • the time, date and place at which its use started and ended
  • the names and contact details of the persons involved in its use
  • the names and contact details of any witnesses to its use
  • the actions are taken in response to its use
  • what other less restrictive options were considered or used before
  • the actions taken leading up to its use, including any strategies used to prevent the need for the use of the practice.
All records must be kept for at least 7 years from the date of the document.

Reporting Authorised Restrictive Practices to the NDIS
If we support clients with positive behaviour support plans that include the routine use of a regulated restrictive practice, we will report on the use of those practices each month to the NDIS Commission. This report will include:
  • type of restrictive practice used
  • a brief description of the practice
  • details of medication (if required)
  • related behaviour concern.
If we support clients with positive behaviour support plans that include as-needed use (PRN) of a regulated restrictive practice, we will report on the use of those practices each month to the NDIS Commission. This report will include:
  • type of restrictive practice used
  • a brief description of the practice
  • details of medication (if required)
  • related behaviour concern
  • date used
  • time commenced
  • time ceased
  • our incident report reference.
If we support clients with positive behaviour support plans that include a regulated restrictive practice, but the practice was not used during the reporting month, we will submit a NIL report to the NDIS Commission.

Suppose we support clients with short-term approval from a state or territory on using a regulated restrictive practice. In that case, we will report to the Commissioner every 2 weeks on using those regulated restrictive practices while the approval is in force.

Supporting Clients When a Restrictive Practice has Been Used
  • If a restrictive practice is used, clients and workers will be immediately supported to manage the impact of the use of restrictive practices.
  • If the incident is deemed reportable, a participant should be immediately referred to and assessed by a medical practitioner (where appropriate). The immediate procedure following a restrictive practice for a client must be detailed in the client's behaviour support plan and in the incident report submitted to the NDIS Commission.
  • Clients, and with their consent, their support network should be included in the review of their support plan following the use of any restrictive practice.
Unauthorised Use of Restrictive Practices
Unauthorised use of restrictive practices is an instance of use:
  • without a positive behaviour support plan and not compliant with state or territory legislation (during transitional stages of the NDIS)
  • without the proper authorisation
  • without knowing that something is a restrictive practice
  • for too long and without regular review
  • for reasons other than keeping people safe
  • to control a person or to make a person act in a certain way
  • as a form of abuse and neglect
  • due to a lack of training, knowledge or reflection about less restrictive alternatives.
If we have instigated any form of unauthorised restrictive practices described above, we must:
  • report the incident to the NDIS Quality and Safeguards Commission within five business days or 24 hours if the incident harmed the participant
  • report the incident to any state or territory as required.
If the regulated restrictive practice is ongoing, then we will:
  • obtain authorisation (however described) for the ongoing use of the regulated restrictive practice from the relevant state or territory as soon as reasonably practicable
  • lodge evidence of that authorisation with the NDIS Commissioner as soon as reasonably practicable after it is received
  • arrange the development of an interim behaviour support plan for the participant by a specialist behaviour support provider that covers the use of the practice within one month after its first use
  • arrange the development of a comprehensive behaviour support plan for the participant by a specialist behaviour support provider that covers the use of the practice within 6 months after its first use.
Training and Worker Requirements
  • The use of restrictive practices poses a serious risk due to the significant and severe impact they have on clients, their support networks, and workers.
  • To mitigate the risks, workers who support clients with a positive behaviour support plan (PBSP) that includes restrictive practices will be trained and at a minimum, understand:
    • what a restrictive practice is
    • what an authorised and unauthorised regulated restrictive practice is, including when, why and how they are to be used according to the positive behaviour support plan
    • their obligations to safely and effectively implement plans
    • the reporting obligations defined in the NDIS (Incident Management and Reportable Incidents) Rules 2018 (Cth)
    • the ethical and safety obligations following the use of restrictive practices, including medical assessments, psychological assistance and debriefing
    • this policy.
  • Workers who implement restrictive practices will work collaboratively with the behaviour support practitioner who developed the PBSP plan and all relevant allied health workers to ensure the safest and most effective plan is implemented.
  • All training will be recorded on our Staff training and development register and periodically reviewed to ensure up-to-date knowledge and practices.
Breach of Policy
A breach of this policy may place the organisation in breach of NDIS Guidelines, which could result in:
  • an investigation into the organisation by the NDIS
  • the organisation being de-registered from the NDIS
  • civil penalties
  • criminal convictions and fines.
Any employee who breaches this policy will face disciplinary action up to termination of employment.