DRAFT
Proposed National Framework for Reducing the Use of Restrictive
Practices in the Disability Service Sector (the ‘Proposed National
Framework’)
Consultation Version – May 2013
Introduction: Reducing the Use of Restrictive Practices
People with disability who display behaviours that are challenging while in the care of
disability service providers may be subjected to restrictive practices that involve
restraint (including physical, mechanical or chemical) or seclusion.
There is currently no national approach to addressing the use and reduction of
restrictive practices by service providers for people with disability across a range of
disability service sector settings including institutional and community based care.
Whilst present day Disability Acts in jurisdictions indicate principles relating to
freedom from abuse; minimum practice standards related to restrictive practices and
respective reviews and monitoring are not explicitly identified in every state and
territory.
Restrictive practices, used in disability services in Australia have been reviewed by
the Commonwealth, States and Territories in relation to the National Disability
Agreement and relevant legislation, and recommendations have been made for a
national framework. Some jurisdictions already have in place or are implementing
advanced, comprehensive strategies and are already achieving a reduction in the
use of restrictive practices.
Reducing and eliminating the use of restrictive practices is consistent with the United
Nations Convention on the Rights of Persons with Disabilities and its intent to protect
the rights, freedoms and inherent dignity of people with disabilities. As a signatory to
the convention, Australia has international obligations to promote, protect and ensure
the full and equal enjoyment of all human rights and fundamental freedoms for all
people with disability, and to promote respect for their inherent dignity.
The commencement of DisabilityCare Australia (formerly known as the National
Disability Insurance Scheme) will significantly change the way disability support is
funded and accessed. DisabiltyCare Australia will be developing and implementing
a quality assurance and safeguards system which will address restrictive practices
and protection for participants. In the interim, DisabilityCare Australia will draw on
existing State and Territory legislation and/or contractual arrangements with service
providers to ensure appropriate restrictive practice laws and policies are observed1.
The future development of an NDIS quality assurance and safeguards system will be
assisted and informed by the nationally agreed elements of this proposed National
Framework.
1
The NDIS legislation and rules recognise that there will be circumstances where the Agency should
make a decision that a support must be provided by a qualified person or organisation that meets
certain quality and practice standards. This will be the case where any restrictive practices are
thought to be necessary to supporting the Participant. This means that in developing the participant
statement of supports, the Agency planners will include appropriate supports for the development or
implementation of a behavioural management plan in the DisabilityCare Participant plan of supports.
DRAFT
DRAFT
Clients of disability services should be active participants in decisions that affect their
lives, support and care. Recognising an individual’s rights is paramount, whereby
restrictive practices represents a deprivation of those rights and freedom. There are
many relevant stakeholders in the use and reduction of restrictive practices - the
client and his or her family, advocates, guardians or significant others, staff at all
levels in the disability service sector, and relevant government agencies.
Disability services are sometimes challenged to provide safe and therapeutic
services for clients who have complex high support needs, as well as providing the
safest possible work environment for staff. It has been recognised internationally
and domestically that restrictive practices can be significantly reduced and in many
cases, eliminated. The proposed National Framework outlines change processes
which require leadership and commitment from officials and staff at all levels of
organisations and provides the opportunity to demonstrate excellence in delivering
safer, quality disability services throughout Australia that are based on evidencebased best practice.
This proposed National Framework is an interim step that delivers leadership toward
reduction of the use of restrictive practices, which will then be incorporated into the
NDIS quality assurance and safeguards that is to be negotiated as part of the full
scheme implementation of the NDIS. The timing of launch sites prior to the
development of a full NDIS quality assurance and safeguards system will mean that
DisabilityCare Australia will be required to assume responsibility for some individuals
subject to these practices in some jurisdictions as part of the launch of the NDIS.
Detailed negotiations will occur between DisabilityCare Australia, the jurisdiction and
the service provider in preparation for transition of these individuals to DisabilityCare
Australia. This will ensure DisabilityCare Australia incorporates appropriate supports
that aligns to this Framework into that person’s plan. Commonwealth, State and
Territory parties who will continue to be responsible for quality assurance systems in
the interim may also explore the possibility of amending their regulatory frameworks
to accompany this initiative. Further consideration will also be given to options
regarding a national or nationally-consistent regulatory framework.
DRAFT
DRAFT
Definitions
A nationally agreed set of definitions will guide legislation and policy development,
and will facilitate greater inter-jurisdictional collaboration on a national strategy to
reduce and safely eliminate restrictive interventions.
Therefore, it is proposed that the following definitions will be used where applicable
by jurisdictions for implementation, reporting and evaluating progress against the
proposed restrictive practices framework.
1. Restrictive intervention
A “restrictive intervention” is defined as any intervention and or practice that has the
effect of restricting the rights or freedom of movement of a person with disability.
2. Seclusion
“Seclusion” means the isolation of a person with disability in a room or physical
space at any hours of the day or night where voluntary exit is prevented.
3. Chemical restraint
A “chemical restraint” means the use of medication or chemical substance for the
primary purpose of influencing a person’s behaviour. It does not include the use of
medication prescribed by a medical practitioner for the treatment of, or to enable
treatment, of a diagnosed mental illness, a physical illness or physical condition.
4. Mechanical restraint
A “mechanical restraint” means the use of a device2 to prevent, restrict or subdue a
person’s movement or to influence a person’s behaviour but does not include the
use of devices for therapeutic purposes.3
5. Physical restraint
A “physical restraint” means the 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.
6. Other restrictive interventions
This includes “other” restrictive interventions to those defined above, such as
those broadly defined as psycho-social restraints, environmental restraints or
consequence-driven restrictive practices.
2
A device may include any mechanical material, appliance or equipment.
Therapeutic purposes may include safe travel such as seat belts during transportation or arm splints
as part of occupational therapy etc.
3
DRAFT
DRAFT
Key Guiding Principles
The following key principles should guide planning, implementation and evaluation of
the National Framework to Reduce the Use of Restrictive Practices in the Disability
Service Sector.
1. Australia’s Human Rights and UN Convention on Rights of Persons with
Disabilities obligations and National Disability Strategy commitments are met:
a. People with disability have the same rights as all people to equality
before the law and to equal protection under the law, without
discrimination.
b. Primary focus of services is to uphold human rights and the well-being,
inclusion, safety and quality of life for people with disability.
c. All effective measures will be taken to prevent people with disability from
being subjected to cruel, inhuman or degrading treatment or punishment.
2. A National Approach:
a. Safeguards should, over time, apply across Australia with comparable
coverage to make sure people have access to the same protections
regardless of where they live.
b. All jurisdictions and levels of government have a duty of care to ensure
that disability services meet high standards focussed on the best
interests of people with disability.
c. The Commonwealth and each State and Territory has its own legislative
framework and most have a policy framework or statement around
reducing restrictive practices.
d. Practices, outcomes and reporting are currently diverse in creating a
representative picture of the use and reduction in restrictive practices – a
national framework aims to deliver a more integrated response between
all governments, but does not change core governance arrangements.
3. Person-Centred Focus:
a. Approaches will be individualised person-centred, proactive and
enhance the quality of life for the person as their focus.
b. To strive for the adoption of evidenced-based best practices that support
and maximise the person’s decision making, choice and self-direction.
c. People with disability, their families, and carers are the natural
authorities for their own lives and are in the best place to communicate
their choices and decisions and should be consulted in any behaviour
support planning.
d. Processes that recognise the person’s authority in decision making,
choice and control should guide the design and provision of services.
DRAFT
DRAFT
4. Delivering Quality Outcomes and Safe Work Places:
a. Policies, procedures and tools should safeguard the rights of people with
disability, focussing on improving clients’ quality of life, reducing the use
of restrictive practices and monitoring the use and reduction in restrictive
practices.
b. Protection against inhuman or degrading treatment – attention to
personal dignity, privacy and self-respect as well as individual needs.
c. Recognise that the use of restrictive practices may reflect a failure in the
service system to understand the nature and function of the individual’s
behaviour, and to respond appropriately to that behaviour.
d. Review mechanisms are developed, maintained and utilised for: client
de-briefing; review of restrictive practices used (incident reporting);
assessment of appropriateness and alternatives; and for aggregated
reporting on an organisational and service provider basis.
5. Accountability through documentation, benchmarking and evaluation working toward transparent and consistent reporting.
a. Transparent reporting mechanisms to ensure accountability and
involvement of stakeholders, and to allow for the analysis of trends to
evaluate the effectiveness of the regulation, and recognise where there
may be an increased reliance on the use of restrictive practices
b. Ability to measure success through a national picture (or stocktake) of
the use and reduction of restrictive practices.
DRAFT
DRAFT
Core Strategies for a National Framework for Reducing of the Use of
Restrictive Practices in the Disability Service Sector
All jurisdictions should implement a set of key core strategies with their respective
service providers by 2018 to reduce the use of restrictive interventions in disability
services. The core strategies presented in this National Framework have been
developed based on national and international evidence based practice in the fields
of mental health and disability.
The six core strategies are:
1. Person Centred Focus
Including the perspectives of service users and carers during restrictive practice
incident de-briefing, individualised care planning, staff education and training, and
policy and practice development is a key element of restraint minimisation across
sectors (Source Note: Azeem et al., 2011).
Key implementation areas are:
a.
Development and regular review of individual behaviour support plans
(including de-escalation and safety) in conjunction with service users and
carers
b.
Development and use of appropriate behavioural and environmental risk
assessment tools by service providers
c.
Development of evidence-based interventions such as teaching the use of
replacement skills (skills the person can use to replace the behaviours of
concern), based on the principles of positive behaviour support.
2. Leadership towards organisational change
Leaders play an important role in facilitating processes, structures and resources for
supporting change. The senior management of services must create a goal of
reducing restrictive practices, and make it a high priority. Leaders must also support
their staff through workforce development opportunities, the development of restraint
and seclusion reduction tools, and implementation of rigorous evidence-based
debriefing techniques to move away from the use of restrictive interventions (Source
Note: Williams and Grossett, 2011).
Key implementation areas are:
a.
Leaders at all levels commit to implement reduction in the use of restrictive
practices
b.
Governments provide strategic direction to service providers
c.
Service providers form relevant governance structures and groups to provide
organisational support mechanisms aimed at reducing restrictive practices.
DRAFT
DRAFT
3. Use of data to inform practice
Mechanisms to trigger periodic review of restraint authorisations, client assessments
and behaviour support plans are necessary to continuously assess the necessity of
restrictive practices and possible restrictive practices alternatives. Data is also
important to determine what factors are effective in reducing the use of restrictive
interventions (Source Note: Webber et al., 2012).
Key implementation areas are:
a.
Collection of data at a service unit and/or organisational level
b.
Identification of baseline data, ability to set improvement and performance
targets, and to evidence how this will be used to reduce reliance on restrictive
practices
c.
Development and maintenance of an auditing tool aimed at auditing when
restrictive practices are used, the frequency with which they are used. The
tool should have capacity to feed back into the support of clients, risk
assessments and service review– preferably integrated with service provider
staffing and management systems.
4. Workforce development
There is good evidence to show that disability support staff who understand positive
behaviour support, functional behaviour assessment as well as a focus on skills for
trauma informed care, risk assessment, de-escalation, and restrictive intervention
alternatives are able to provide good support and reduce their use of restrictive
interventions to people who have complex needs.
Key implementation areas are:
a.
Training and education for staff and managers, including on restraint
reduction, risk assessment and positive behaviour support
b.
Service providers implement guidelines, processes and protocols for staff and
managers
c.
Debriefing and support – continuous improvement for staff at all levels.
5. Use within services of restraint and seclusion reduction tools
Restrictive practices reduction tools need to be based on core assessment and
prevention approaches, the results of which need to be integrated into each
individual’s support plan.
These approaches would include:
 Proven assessment tools which screen for increased risk of violence, physical
and emotional issues which counter-indicate restrictive interventions
 Emergency management plans
 Changes to the therapeutic environment
 Introduction to meaningful activities. (Source Note: Huckshorn, 2005).
Key implementation areas are:
a.
Practice guides and reference material for staff, and managers
b.
Integration with service provider staffing and management systems.
DRAFT
DRAFT
6. Debriefing techniques
Following an emergency use of a restrictive intervention, an immediate “post event”
debriefing is completed on site led by the appropriate senior staff member on duty.
The goal of this immediate debriefing is to ensure that everyone is safe, that
satisfactory information is available to inform the later structured debriefing process
and that the consumer subject to the restraint is safe and being appropriately
monitored. Formal debriefing occurs one to several days after the event and includes
all involved, the treatment team and relevant administrative staff. The structure of the
formal debriefing should follow the steps taken in a root cause analysis. The
consumer or their proxy must be involved in all stages of the debriefing process.
(Source Note: Huckshorn, 2005).
Key implementation areas are:
a.
Practice guides and reference material for staff at all levels.
Measuring Performance/ Effectiveness
Jurisdictional reporting on progress of the implementation of the National Framework
will occur on a biennial basis. Monitoring of the National Framework for reducing the
use of restrictive practices in the disability service sector will provide enhanced
accountability, public transparency and a national picture and measurement of
effectiveness. By 2018, all jurisdictions are encouraged to implement a data
monitoring system that integrates with existing service delivery management
systems.
This work will initially focus on seeking agreement to achieve standardised data
collection and reporting (including for voluntary reporting where commitments occur)
in order to establish benchmarks and performance indicators that measure
effectiveness in reducing restrictive practices over time. Milestones will be
developed which take an incremental approach toward reaching data reporting
capacity on the use of restrictive practices by services.
Future opportunities may arise through the evaluation of the National Framework, for
expansion of these six core strategies to be integrated into other mainstream service
sectors that support people with disability such as in health, education and criminal
justice.
DRAFT
DRAFT
References
Azeem, M.W., Aujla, A., Rammerth, M, Binsfeld, G., & Jones R.B. (2011).
Effectiveness of six core strategies based on trauma informed care in reducing
seclusions and restraints at a child and adolescent psychiatric hospital. Journal of
Child and Adolescent Psychiatric Nursing 24, 11–15.
Huckshorn, K.A. (2005). Six Core Strategies to Reduce the Use of Seclusion and
Restraint Planning Tool. Alexandra, VA: National Technical Assistance Centre.
Sanders, K. (2009). The effects of an action plan, staff training, management support
and monitoring on restraint use and costs of work-related injuries. Journal of Applied
Research in Intellectual Disabilities, 22, 216–220.
Webber, L.S., Richardson, B., Lambrick, F., & Fester. (2012). The impact of the
quality of behaviour support plans on the use of restraint and seclusion in disability
services. International Journal of Positive Behavioural Support, 2 (2) 3-11.
Williams, D.E., & Grossett, D.L. (2011). Reduction of restraint of people with
intellectual disabilities: An organizational behavior management (OBM) approach
Research in Developmental Disabilities 32, 2336–2339.
DRAFT