What are restrictive practices and why are they used?
According to the NDIS Quality and Safeguards Commission, a restrictive practice is any practice or intervention that restricts the rights or freedom of movement of a person with disability.
To protect the rights of people with disability and deter unethical practices that humiliate, punish, or cause physical and mental pain and harm, the Australian Government has strict regulations relating to the use of restrictive practices.
These regulations stipulate that restrictive practices (RPs) must be reported to the Commission and can only be used to reduce the risk of harm to the person with disability displaying behaviours of concern or others around them, and only after the registered provider has explored and applied evidence-based, person-centred and proactive strategies. A restrictive practice must also be
– the least restrictive response to ensure the safety of the person with disability or others;
– used for the shortest possible time;
– and only with a behaviour support program in place that focuses on the reduction and elimination of the RP.
Each restrictive practice must be proportionate to the potential negative consequences of the behaviour of concern it responds to. “At Better Rehab we support the government’s goal to reduce and eliminate the use of restrictive practices by supporting participants’ behavioural needs and improving their quality of life,” says Better Rehab Clinical Lead, Positive Behaviour Support, Emma McCarthy.
What are behaviours of concern?
Behaviours of concern are those which have the potential to impact the wellbeing and/ or safety of the person engaging in them, as well as other people that are in close proximity. Behaviours of concern may cause physical harm, emotional distress, strain social relationships, or result in the reduction/ elimination of participation in community activities
“Behaviours of concern serve a purpose, such as expressing unhappiness, distress, or anxiety about something or about a need that isn’t being met,” explains Emma.
How positive behaviour support reduces and eliminates the use of RPs
When a restrictive practice is in place, positive behaviour support (PBS) practitioners are focused on reducing and then eliminating it as quickly and safely as possible for the participant and the other people in their life.
“When a participant has behaviours of concern, their PBS practitioner will work closely with them and their family and support network to ensure an RP is the last resort, and only used when proactive, evidence-based and person-centred interventions haven’t reduced these behaviours,” explains Emma.
PBS practitioners develop support strategies that aim to reduce and eliminate reduce and eliminate behaviours of concern based on the participant’s needs, goals, and individual circumstances. At the core of any strategy are the findings of the functional behaviour assessment (FBA), which is a process for collecting information to help determine why behaviours of concern occur. Conducting an FBA is a requirement of the NDIS.
Positive behaviour support that addresses behaviours of concern and reduces and eliminates the need for restrictive practices can include:
- improving a participant’s communication skills to help them express their thoughts and needs more effectively, which can reduce feelings of frustration and anger;
- removing or reducing any triggers of behaviours of concern (this can include making changes to their environment, such as at home and school, routine and activities);
- giving them techniques to manage their challenging feelings and behaviours;
- and working closely with their family, carers, support workers and teachers to provide guidance on managing and reducing their behaviours of concern.
“Our PBS practitioners work to improve every participant’s quality of life with person-centred support, respect, empathy, choice and positivity. Once we understand the reasons for a participant’s behaviours of concern, we can provide them with other ways to communicate their feelings and needs, and ways to manage their response to the triggers of their challenging behaviour, which can involve coping and emotional regulation skills.
“Our practitioners might also recommend changes to the participant’s daily schedule, activities, and home, to better meet their needs and help make them feel empowered, secure, and happy. And we may recommend therapy from another allied health professional, such as an occupational therapist, speech pathologist, physiotherapist or exercise physiology to help the participant overcome difficulties that might be influencing their behaviour and affecting their quality of life.
“For positive behaviour support to be effective, practitioners also need to take the time to get to know their participants – their home life, their likes and dislikes, culture, beliefs, religion, sexual expression, aspirations – involve them in their PBS program from day one and help them feel empowered in their lives. And as improved quality of life can mean different things to each person, listening to participants is vital for choosing support that helps them have what they need to enjoy life, achieve their goals and thrive,” says Emma.
The role positive behaviour support practitioners play in restrictive practice introduction and management
There are many considerations and actions involved in introducing and managing a restrictive practice to ensure the safety and wellbeing of the participant.
“Our PBS practitioners inform each participant and their family and carers of any intention to use a regulated restrictive practice. This ‘supported decision making’ is a collaborative and consultative approach that helps participants make decisions about their behaviour support strategies, involves them in their support, and empowers them. Explaining why the participant needs a temporary restrictive practice, how it will ‘work’, and the benefits to them and others can help them understand its role and accept it.
“And to help ensure any restrictive practices are conducted as per the behaviour support plan, our practitioners also work closely with each participant’s support network who will implement the behaviour support plan and the restrictive practice,” explains Emma
Better Rehab’s PBS practitioners recognise the high prevalence of traumatic experiences in people with disability and ensure any restrictive practices in place don’t re-traumatise them.
In fact, before a restrictive practice is chosen and actioned, a medical practitioner is required to exclude any medical or physical conditions behind a participant’s behaviours of concern, and allied health clinicians, such an occupational therapist, speech pathologist, or physiotherapist, might work in a multidisciplinary team to assess the participant’s context, systems and environment in which the RP will be used.
“Our PBS practitioners will also conduct a physical and psychologist risk assessment that takes into account any physical health problems, such as musculoskeletal risks, psychologist risks, such as a history of abuse, risk of injury and health concerns. And they will also consider the individual – such as the participant’s culture, religion, sexual expression, beliefs, linguistic circumstances, gender, and family,” says Emma.
Throughout the use of a restrictive practice, the participant’s PBS practitioner will regularly monitor and review the practice and the participant’s progress as well as maintain a detailed report for the NDIS to review.
“Ultimately, we don’t want any participant to have a restrictive practice, and everyone who supports people with disability – family members, support workers, carers, medical professionals, allied health clinicians, and their friends – yearn for a future in which be restrictive practices are no longer used,” says Emma.
The 5 NDIS regulated restrictive practices PBS can assist with reducing and eliminating:
- Seclusion
Seclusion is when a person with disability is confined at any time of the day or night on their own in a room or physical space where their leaving is prevented, not facilitated, or permission to leave denied, either expressly or implied.
- Physical restraint
Physical restraint is the use or action of physical force to prevent, restrict or subdue the movement of a person’s body, or part of their body, with the primary purpose of influencing their behaviour. Physical restraint doesn’t include the use of a hands-on technique in a reflexive way to guide or redirect a person away from potential harm or injury, consistent with what could reasonably be considered the exercise of care towards a person. This type of restraint can include holding a person’s hand down to prevent them from hitting themselves, taking their arm and pulling them in a direction they don’t want to go, and holding down a part of their body.
- Mechanical restraint
Mechanical restraint is the use of a device to prevent, restrict or subdue a person’s movement to influence their behaviour. This type of restraint does not include the use of devices for therapeutic or non-behavioural purpose. A mechanical restraint can be clothing that restricts movement and cannot be removed by the wearer, Velcro straps, seatbelt locks, a special harness for travelling in vehicles, and locking the wheelchair brakes. Mechanical restraints that can cause harm to the person, such as handcuffs, devices that stop legs and feet moving, and ropes that tie hands and other body parts are abusive and illegal and must be reported to the NDIS Commission.
- Environmental restraint or restricted access
Environmental restraint restricts a person’s free access to all parts of their environment, for example their home, and this includes items or activities. This type of restraint can include locking the front door and only staff having the key, locking food cupboards, the fridge, and certain rooms, and not being able to access the community or the garden at home.
- Chemical restraint
Chemical restraint is the use of medication or chemical substance for the primary purpose of influencing a person’s behaviour. This type of restraint doesn’t include the use of medication prescribed by a medical practitioner for the treatment of a diagnosed mental disorder, physical illness or physical condition. Misuse of chemical restraint includes over-medication and giving medications differently to how they are prescribed, the use of psychotropic medications when behaviours may not be occurring, menstruation suppression, and long-term use of medication without a review to reduce its use.
