A restrictive practice refers to any action that limits the rights or freedom of movement of a care recipient. There are five main types of restrictive practices:
- Chemical restraint
- Environmental restraint
- Mechanical restraint
- Physical restraint
- Seclusion
These practices are used in certain situations to ensure the safety and well-being of the individual receiving care. Care workers and healthcare professionals need to be aware of these practices and use them judiciously to maintain the dignity and autonomy of the care recipient.
Minimising the Inappropriate Use of Restrictive Practices in Aged Care
Effective July 1, 2021, amendments to the Aged Care Act 1997 and Quality of Care Principles 2014 have been implemented to regulate and strengthen the use of restrictive practices in Australian Government-funded residential aged care facilities. These changes aim to enhance the safety and well-being of care recipients, as well as to reinforce reporting requirements for approved providers.
The Aged Care and Other Legislation Amendment (Royal Commission Response) Act 2022 has introduced additional legislative amendments to further enhance consent requirements and address gaps in state and territory legislation regarding the use of restrictive practices.
The Aged Care Clinical Advisory Committee is dedicated to reducing the use of restraint in residential aged care by providing expert advice on clinical policy and legislative oversight.
In addition to these measures, there are other initiatives in place to minimize the inappropriate use of restrictive practices, including:
- mandatory reporting of such incidents through the Serious Incident Response Scheme (SIRS)
- reporting on the use of all restrictive practices (excluding chemical restraint) through the National Aged Care Mandatory Quality Indicator Program (QI Program).
- adherence to the Aged Care Quality Standards is essential in ensuring the appropriate use of restrictive practices in aged care facilities.
A restrictive practice should only be implemented as a last resort to prevent harm to a care recipient or others, taking into consideration its impact on the individual receiving care. Before resorting to any restrictive practice, providers are required to test and document alternative strategies. Additional support is readily available to help manage behaviors that may pose a risk to the care recipient or others.
Dementia Support Support Australia (DSA) offers services aimed at assisting individuals living with dementia who are experiencing behavioral changes. Meanwhile, Dementia Training Australia (DTA) provides a range of free online dementia training courses, practical resources, and training packages. DTA also offers in-person training sessions to providers and professionals in the sector. These resources are designed to help staff gain a better understanding of the root causes of behavioral changes and learn effective strategies to prevent or minimize them.
Provider Responsibilities
Approved providers have a responsibility to always consider the rights of care recipients and comply with legislative obligations. When utilizing a restrictive practice, approved providers must adhere to the following guidelines:
- Use restrictive practices as a last resort to prevent harm to a care recipient or others, after carefully evaluating its impact on the care recipient.
- Trial and document alternative strategies before resorting to restrictive practice.
- Implement the least restrictive form of practice for the shortest duration necessary.
- Obtain informed consent from the care recipient or their restrictive practices substitute decision-maker (RPSDM) before using the practice.
- Ensure that the use of restrictive practices aligns with the rights and responsibilities of care recipients as outlined in the Charter of Aged Care Rights
- Monitor and regularly review the use of restrictive practices.
Approved residential aged care providers are required to include a Behavior Support Plan (BSP) in the existing Care and Services Plan for all care recipients who
- exhibit behaviors of concern,
- undergo assessment for the need for restrictive practices,
- have restrictive practices applied to them.
The Aged Care Quality and Safety Commission (ACQSC) is dedicated to safeguarding the safety, health, and well-being of care recipients.
The ACQSC collects and evaluates information on the use of restrictive practices to ensure that approved providers are following:
- legislative obligations,
- the Charter of Aged Care Rights,
- the Aged Care Quality Standards.
For more information to assist approved providers in meeting their requirements regarding restrictive practices, please visit the ACQS website.
Informed consent is a crucial aspect when it comes to the implementation of restrictive practices
Consent must be obtained from either the care recipient or a Representative of a Person with Decision-Making Capacity (RPSDM) in cases where the care recipient is unable to provide consent.
A RPSDM is an individual or entity authorized to provide informed consent for the use of restrictive practices. They also have the authority to consent to the prescription of medication for chemical restraint purposes. All consent procedures must adhere to the laws and regulations of the state or territory where the care recipient is receiving aged care services.
Ensuring that informed consent is obtained clearly and transparently is essential to upholding the rights and dignity of elderly individuals in residential aged care settings. It is crucial to prioritize the well-being and autonomy of care recipients while also complying with legal requirements.
Temporary procedures for obtaining consent for restrictive practices
The Quality of Care Principles 2014 establishes a hierarchy for determining who has the authority to consent to the use of restrictive practices on behalf of a care recipient is:
- unable to provide consent themselves,
- when there is no clear legal process in place to appoint a Restrictive Practices and Safeguards Decision Maker (RPSDM) under state or territory laws,
- when there is a substantial delay in the decision-making process for appointing an RPSDM.
There are five levels of the hierarchy for determining who can give consent for restrictive practices:
- Restrictive practices nominee – an individual or group nominated by the care recipient, able to give informed consent if the care recipient lacks capacity, has agreed in writing, and can give consent.
- Partner – the partner of the care recipient with a close continuing relationship, who has agreed in writing to act as the RPSDM and can give consent.
- Relative or friend who was a carer – a person who was the unpaid carer immediately before the care recipient entered care, has a personal interest in the care recipient’s welfare, a close continuing relationship, agreed in writing to act as the RPSDM, and can give consent.
- Relative or friend who was not the carer – a person with a personal interest in the care recipient’s welfare, a close continuing relationship, agreed in writing to act as the RPSDM, and can give consent.
- Medical treatment authority – an individual or body appointed under the state or territory law where the care recipient receives aged care, able to give informed consent for medical treatment if the care recipient lacks capacity.
This hierarchy is an interim measure to allow time for state and territory governments to update their consent and guardianship laws. Originally intended to sunset on December 1, 2024, the application period was extended to December 1, 2026, to ensure all states and territories have appropriate laws in place.
Responsibilities of Medical Practitioners in Aged Care
Medical practitioners who work with care recipients in aged care facilities have a crucial role in ensuring the safety and well-being of those under their care. Medical practitioners need to always prioritize the safety and health of care recipients.
Before prescribing psychotropic medications, medical practitioners are required to explore and document alternative strategies in the care recipient’s clinical record. There are guidance materials available to assist medical practitioners in this process, such as information on:
When considering the use of chemical restraints, medical practitioners must follow specific guidelines. They must first assess the care recipient to determine if:
- they pose a risk of harm to themselves or others.
- a chemical restraint should only be considered a last resort
- medical practitioners are also required to discuss the proposed benefits, risks, and alternatives with the care recipient or their representative,
- seeking their informed consent before prescribing the medication
- Medical practitioners must communicate that informed consent has been obtained from the approved provider in a mutually agreed-upon manner before prescribing the medication.
In some cases, approved providers may request that a medical practitioner assess the need for restrictive practice and provide evidence to support its use. The approved provider is responsible for documenting this information in the care recipient’s Behavioral Support Plan (BSP).
How Medical Practitioners Can Assist in Aged Care
Medical practitioners play a crucial role in the care of residents in aged care facilities and in reducing the inappropriate use of restrictive practices. There are numerous ways in which practitioners can support approved providers in meeting requirements and ensuring the safety and well-being of residents. Some of these ways include:
- Assessing the potential contribution of current medications to confusion, sedation, or other side effects that may cause distress or problematic behaviors.
- Identifying and documenting the risks of harm to oneself or others that medications used as restraints aim to address.
- Communicating prescribing decisions with the aged care provider and relevant staff.
- Obtaining informed consent from the resident or their representative and sharing this consent with the provider.
- Specifying the necessary monitoring for potential side effects.
- Emphasizing the need for ongoing evaluation of the effectiveness and impact of medications, as well as when these evaluations will take place.
- Clearly defining the circumstances under which sedating medications can be used on an ‘as needed’ basis.
- Regularly reviewing medications, particularly psychotropic drugs, to facilitate deprescribing at the earliest opportunity.
- Collaborating with other prescribers, past or present, in cases where the reasons for prescribing and review responsibilities are unclear.
By following these guidelines, medical practitioners can contribute significantly to the well-being and quality of care provided to residents in aged care facilities.