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What Are The Limitations And Legal Ramifications Of Psychological Restraint

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What Is Chemical Restraint And Is It Legal

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Possibly even more horrifying than physical restraints are chemical restraints. According to the same Quality Care Principles, chemical restraint should be used only as a last resort, and an approved provider must not use a chemical restraint on a patient unless:

  • A medical practitioner or nurse practitioner has assessed the patient, determined that they require the restraint, and prescribed the medication used for chemical restraint
  • The practitioners decision to use the restraint and its subsequent use have both been fully recorded in the care and services plan documented for the patient
  • The patients representative is informed before the restraint is used

Is Restraint Physical Abuse

Restraint can be physical abuse if it is applied incorrectly or illegally. In such cases, this would fall under the purview of appropriate authorities, and should be reported as elder abuse. The care your loved one recieved would be investigated and a determination made as to whether a crime had been committed.

Nursing home abuse is unfortunately all too common and vigilance is required to protect your ageing family members. The last thing you want to find out is that they have been restrained for no good reason, or as punishment for any behaviors or accidents, such as wetting themselves, exhibiting signs of dementia or disturbing nursing home staff.

Overall Assessment Of The Quality Completeness And Applicability Of Evidence

We chose to include a broad range of outcomes for effects of seclusion and restraint in adult psychiatry. We found 35 relevant articles with significant or exploitable results, but also a high heterogeneity with respect to the study designs and the explored outcomes. There are only three published RCTs, which point out the challenge of obtaining usable data to prove clinical efficiency and to identify benefits or harms of seclusion and restraint on patients with severe mental disorders. In an era of evidence-based medicine, it shows that daily clinical practices can still be traditional habits, more than therapeutic methods proven to be effective. This finding does not mean that coercive methods are not necessary in certain cases, but in the context of limiting human rights and potential deleterious consequences, the limitations of the evidence base should invite medical and nursing staff to question their practices and to use them with caution and with hindsight when the decision to use them is made.

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Why Restraints Should Not Be Used On Nursing Home Residents

The laws that govern the care of nursing home residents differ from those that govern the care of hospital patients. Nursing home residents require assisted care, but the nursing home facility is their permanent home. As such, basic human rights such as privacy, and safety are of utmost concern. Nursing home residents should not be confined for safety reasons unless all other measures have been exhausted.

A Patchwork Of Existing Laws And Policies

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8.26 Stakeholders expressed significant concerns about the unregulated use of restrictive practices and were supportive of the ALRCs proposal for national reform.

8.27 Regulation of restrictive practices occurs at a state and territory level under disability services and mental health legislation, and under a range of policy directives, statements and guidance materials. There is substantial discrepancy in the regulation of restrictive practices across jurisdictions, and the numerous frameworks conspire to make the legal framework in this area exceedingly complex.

8.28 Robust regulation that applies specifically to restrictive practices occurs in Victoria, Queensland and Tasmania through disability services legislation. The approach in other jurisdictions includes policy-based frameworks, voluntary codes of practice, and regulation as an aspect of guardianship .

8.29 In the context of the mental health system, Victoria and Queensland have detailed provisions relating to restrictive practices, combined with minimum standard guidelines and a policy statement. Legislative provisions are less prescriptive in other jurisdictions. In NSW, the use of restrictive practices is regulated by a lengthy policy directive. Mental health legislation is an area of ongoing review and reform, with implications for the regulation of restrictive practices.

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Use Strategies Tools Resources And Training To Minimise Restraint

Restraint is practised in mental health services and other health service organisations. Minimising and, if possible, eliminating the use of restraint and seclusion were identified as a national safety priority for mental health services in Australia in 2005.4

The key to minimising use of restrictive practices is to be alert to changes in a persons behaviour or demeanour that may suggest a deterioration in their mental state. Be receptive to information from the person themselves, and from their carers and families. People who have experienced mental health issues, or cared for someone who does, often have detailed knowledge about what can lead to a deterioration in their mental state, and what strategies are most effective for restoring their capacity to manage their mental state without the use of restrictive practices. These principles are outlined in the National Consensus Statement: Essential elements for recognising and responding to deterioration in a persons mental state.

The National Seclusion and Restraint Project identified six main strategies for health service organisations to minimise restraint:

  • Leadership towards organisational change
  • Use of restraint and seclusion reduction tools
  • Improving the consumers role
  • Debriefing techniques.

In 2015, SA Health released a suite of documents relating to the use of restrictive practices in health care, including a policy framework, guidelines, implementation tools and fact sheets for clinicians.

Funding For Residential Aged Care Quality And Safety

On 1 March 2021, the Australian Government announced $7.3 million to change the culture around the use of physical and chemical restraint. This extra funding recognises the findings of the:

  • Independent review of legislative provisions governing the use of the restraint in residential aged care .

This funding will improve behaviour support capability in residential aged care by:

  • introducing legislation from 1 July 2021 to strengthen the regulation of restraint, and to ensure these practices are only used as a last resort
  • appointing a senior practitioner to the Aged Care Quality and Safety Commission to lead education of residential aged care providers and GPs on minimising the use of restrictive practices.
  • extending the Aged Care Quality and Safety Commissions Better Use of medication in aged care Program to 2025.

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Restraint In Nursing Practice

The following three scenarios, drawn from anonymised practice examples, show the complexity of this issue in everyday practice. Put yourself in the position of the nurse then respond to these questions:

  • Can the nurses actual or expected intervention be described as restraint?
  • If so, what type of restraint?
  • What ethical arguments can be presented for and against the intervention?
  • What alternatives are there?

Objectives And Research Question

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The aim of this study is to conduct a systematic literature review on the negative and potentially beneficial effects of seclusion and restraint on adult psychiatric inpatients, compared to non-exposure or to exposure to other coercive measures. This review should permit establishing the potential harms and benefits of these measures and, therefore, provide an improved evidence base for making decisions in acute psychiatric care. In addition, through systematic synthetization of available baseline data, this review should provide arguments for later implementation of coercion reduction programs. Finally, we aim to synthesize the methods used to study the topic in order to propose a systematic approach for structuring research and improvement of the evidence basis.

As Sailas and Fenton found already in 2012, there have been only two randomized controlled trials on the effectiveness of seclusion and restraint . We chose to widen the search to prospective observational studies with various outcomes measuring benefits and harms of seclusion and restraint. Even though this approach limits the evidence level, it will allow for a broader appreciation of the consequences of interventions limiting liberty of movement.

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The Impact Of Physical Restraint On People In Mental Health Settings

What is meant by physical restraint in a mental health context? An international broad definition describes it as the prevention of a persons free movement . This is defined more specifically in the UK as direct contact with an intention to prevent, restrict or subdue a persons movement in order to prevent harm or give treatment .

Physical restraint is also defined within the literature as a hard form of coercion commonly observed in mental health inpatient settings . It is a controversial element of mental health treatment and perhaps symbolises for many a lack of genuine participation in ones own treatment, especially at times of distress. Indeed, recent media reports of findings from an independent review of the Mental Health Act describe an increasing use of detentions in mental health services and concern regarding the manner in which people are treated.

Recently Matthew Broome blogged here on The Mental Elf about whether or not and commented on a complex dynamic between collaboration and coercion impacting on therapeutic relationships. The administration of physical restraint is an example commonly seen in mental health practice where distressed behaviour directly confronts practitioners professional responsibilities and accountabilities. It presents practitioners with a difficultly of balancing both the rights and wellbeing of individual patients with those of other people. During physical restraint, shared decision making is severely lacking.

Wrongful Use Of Restraints In Nursing Home Residents

When a restraint is wrongly used in the nursing home, the resident or the residents family may have legal recourse against the nursing home. Sometimes, restraints that are intended to prevent are injury actually cause the injury or death of a nursing home resident. All restraints are dangerous to a resident, and must be used with careful supervision and monitoring. Possible injuries from restraints can include:

  • Falls
  • Psychological effects such as depression, fear, or agitation
  • A reduction in the ability to enjoy life or perform self-care activities
  • Death

When a restraint is used, the resident is then at the complete mercy of others for his or her safety. This puts the resident at a greater risk for elder abuse, sexual abuse, psychological abuse, or violence perpetrated by other nursing home residents.

Nursing homes that are experiencing a staffing shortage may be tempted to increase the number of restraints in use to make-up for the lack of supervision. Residents are especially at risk for application of illegal restraints during the nighttime hours, when staffing may be at its lowest. If your loved one has not previously been prescribed a restraint, and you suspect an illegal restraint is being used, you may notice symptoms such as:

  • Sheets tucked into the mattress so tightly that a resident is unable to move
  • Solitary confinement to a room
  • Chemical restraints, such as Thorazine, Ativan, Haldol, or Versed

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Who We Work With

The Aged Care Quality and Safety Commissions focus is to minimise the use of restrictive practices in residential aged care. Where a restrictive practice is used, it must be in line with:

From 1 September 2021, the Aged Care Quality and Safety Commission will monitor a residential aged care providers compliance with the restrictive practice requirements. These include having:

  • a Behaviour Support Plan in place for every care recipient who has a restrictive practice used or applied to them
  • policies and processes in place to support appropriate use of restrictive practices, including documentation of consent, for care recipients.

The Aged Care Clinical Advisory Committee advises us and the Aged Care Quality and Safety Commission on initiatives to reduce the use of restrictive practices.

The Harmful Effects And Risk Of Chemical Restraints

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Chemical restraints are incredibly dangerous. Using powerful psychotropic drugs has clear risk on a persons physical and mental health, and should only be used when absolutely necessary. Chemical restraints on the other hand are used when there is no clear medical purpose. Because the users are elderly and are often taking more than five medications already, the risk of harm is greatly increased. According to the FDA, unnecessary use of antipsychotic medication kills 15,000 nursing home patients every year.

Of all the drugs used as chemical restraints, antipsychotics are the most widespread and may be the most dangerous. The federal government has spent years warning facilities about their dangers, especially the damage they can do to the heart and cardiovascular system of someone with dementia. Despite these warnings, more than 88% of the antipsychotic drugs used in nursing homes are used on patients who have dementia.

Using these drugs unnecessarily will expose a patient to a number of other risks and harmful effects including:

  • Increased dependence and functional decline
  • Loss of memory
  • That may cause serious adverse effects or interactions

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Know The Types Of Restraint

Restraint is the restriction of an individuals freedom of movement.1 It includes mechanical restraint, physical restraint, and chemical or pharmacological restraint.

Mechanical restraint is the application of devices to a persons body to restrict their movement. This is to prevent the person from harming themselves or endangering others, or to ensure that essential medical treatment can be provided. It does not include the use of furniture that restricts the persons capacity to get off the furniture, except when the devices are only used to restrain a persons freedom of movement. The use of a medical or surgical appliance for the proper treatment of physical disorder or injury is not considered mechanical restraint.

Physical restraint is the application by members of the healthcare workforce of hands-on immobilisation or the physical restriction of a person to prevent them from harming themselves or endangering others, or to ensure that essential medical treatment can be provided.2

Improper Use Of Restrictive Practices

8.11 While restrictive practices are used in circumstances to protect from harm the person with disability or others around them, there are concerns that such practices can also be imposed as a means of coercion, discipline, convenience, or retaliation by staff, family members or others providing support.

8.12 Many stakeholders raised systemic issues across various sectors which result in inappropriate or overuse of restrictive practices. A key explanation for the use of restrictive practices may be the lack of resources for positive behaviour management and multi-disciplinary interventions to challenging behaviours. Such behaviours may be better understood as a legitimate response to difficult environments and situations or adaptive behaviours to maladaptive environments.

8.13 As the Chief Executive Officer of Alzheimers Australia explained to the Senate Inquiry into dementia, it is important to look beyond behaviours to understand the reasons for them:

8.14 There is also evidence that what constitutes a restrictive practice is contested, which may result in inadvertent and misguided use of restrictive practices. A representative of the Royal Australian College of General Practitioners told the Senate Inquiry into dementia:

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New Laws On Physical And Chemical Restraints In Nursing Homes

Posted onAuthorTom Maling

The Federal Government has introduced a new law dealing with use of physical and chemical restraints in Aged Care Facilities/Nursing Homes. It is called the Quality of Care Amendment Principles 2019 .

We have been advocating for regulation of chemical restraint use in nursing homes for some time. In this post, we take a look at this new law. In our view, older Australians in nursing homes are still not subject to appropriate legal protections.

Every Adult Has the Right to Choose and Refuse Treatment

The bedrock of health and medical treatment is consent. You must give permission to the health practitioner to administer a medication or give treatment.

In 1914 a famous American judge said: Every human being of adult years and sound mind has a right to determine what shall be done with his own body and a surgeon who performs an operation without his patients consent commits an assault. This has been quoted many times by Australian judges and so forms part of Australian law.

The law recognises that if a doctor or nurse administers medical treatment without the consent of the patient, they have committed an assault. If no consent is provided then the doctor or nurse has committed a criminal assault or a battery at civil law.

Can a Hospital Use Physical or Chemical Restraints for Treatment?

Not unless a special law authorises. For example, in the ACT:

The key point is that there must be a special law which authorises the restraint.

Fig 1 Analysing Ms Morgans Situation

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Medical indications

What are the goals of care and treatment for Ms Morgan? Is her diagnosis of bipolar disorder correct? What are the probabilities of different interventions achieving the goals of treatment and care?

Patient preferences

Does Ms Morgan have capacity? If so, what does she want? If not, has she expressed preferences in an advance directive . Is she willing or unwilling to cooperate with care and treatment? Why? Is her autonomy respected?

Quality of life

What distress is Ms Morgan experiencing? Will her quality of life after intervention be acceptable to her?Or might intervention compromise the success of future care? What interventions will enhance her quality of life? How can intervention benefits be maximised and harms minimised? After the acute episode, how can nurses collaborate with her to minimise the chances of such situations happening again?

Contextual features

What family issues might influence decision-making? Is there a staff member, family member or friend Ms Morgan trusts who could help to gain her cooperation? What religious, cultural or legal issues need to be taken into account? Are there conflicts of interest? What interventions, for example, are in her best interests if she lacks capacity? Are staff working within the law?

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Restrictive Practices In Residential Aged Care

A restrictive practice is any action that restricts the rights or freedom of movement of a care recipient. Legislation changes effective 1 July 2021 strengthen arrangements, using the term restrictive practice instead of restraint.

There are 5 types of restrictive practices:

  • chemical restraint
  • seclusion.

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