Voluntary Code of Practice
for the Elimination
of Restrictive Practices
Disability Services Commission
August 2012
Contents
Overview ...................................................................................................................... 1
Part One — Overview of the purpose and context of the code of
practice ........................................................................................................................ 1
1.1
Purpose ............................................................................................................. 1
1.2
Context .............................................................................................................. 1
1.3
Key terms and definitions ................................................................................ 2
Part Two — Development of operational policy and guidelines to
assist with service implementation.................................................................... 2
2.1
Considerations to achieve systemic change in service delivery.................. 2
2.2
Service Guidelines ............................................................................................ 3
2.3
Code of practice review .................................................................................... 7
Appendices
1
International, National and State Obligations................................................. 9
2
Definitions and Key Terms ............................................................................. 11
To support disability sector-wide engagement in the
elimination of restrictive practices
Overview
This code of practice provides the basis for the disability sector to develop operational
policy and guidelines for eliminating the use of restrictive practices. It applies to all
services provided and funded by the Disability Services Commission for children and
adults with disability.
The code of practice has been developed by a coalition of partners from across the
disability sector. Disability sector organisations are strongly encouraged to adopt the
practice guidelines contained within the voluntary code which is consistent with
Standard 9 of the Disability Service Standards. Support and training for implementation
of the code of practice is available through the work of the Positive Behaviour
Framework Guiding Committee.
This code of practice is divided into two parts:


Part One which provides an overview of the purpose and context for the code of
practice.
Part Two which is to inform the development of operational policy and guidelines
to assist with service implementation.
Part One — Overview of the purpose and context of the code of
practice
1.1
Purpose
The purpose of this code of practice is to:


1.2
Contribute to the elimination in the use of restrictive practices for people with
disability who sometimes exhibit challenging behaviours
ensure safeguards are in place in exceptional circumstances where it is
necessary to use restrictive practices to protect the welfare of individuals and the
safety of third parties.
Context
The Commission’s 2009 Positive Behaviour Framework has promoted a coordinated
statewide approach to Positive Behaviour Support and has been guided by the Towards
Responsive Services for All report in the implementation of this strategy. The essential
elements of Positive Behaviour Support are highlighted in a paper developed after
1
sector-wide consultation (the Effective Service Design report) which highlights those
elements of service design and delivery that if applied, would lead to a significant
reduction or elimination in the need for use of restrictive practices.
This code of practice on eliminating restrictive practices is the next stage of
implementing the Positive Behaviour Framework and has been jointly developed by
representatives from a broad range of disability sector organisations, people with
disability, families, carers, advocacy organisations, other government agencies including
the Office of the Public Advocate and State Solicitor’s Office, and the Commission.
International, national and state obligations in relation to the human rights of people with
disability underpin the development of this code of practice (refer to Appendix 1).
1.3
Key terms and definitions
Key terms associated with the identification, reduction and elimination of restrictive
practices are defined in Appendix 2. For terms which have been bolded in this document
please refer to Appendix 2.
Part Two — Development of operational policy and guidelines to
assist with service implementation
2.1
Considerations to achieve systemic change in service delivery
The implementation of this code of practice will require systemic change over time in the
Western Australian disability services sector. Considerations for the disability sector to
achieve this include:




significant changes in current service design and practices
significant cultural change
increased interdisciplinary liaison and collaboration between services
new approaches to staff training.
The well-being and safety of people with disability, their families and the staff who
provide services will be a primary consideration during the transition from old to new
practices as required by this code of practice.
Operational implementation of the policy will be the responsibility of each service
provider and will take into account the types of service provided and the assessed
needs and abilities of each person for whom the services are provided.
Service providers should only withdraw existing restrictive practices when they are
satisfied that:


safe and more respectful alternatives have been developed
staff have had the appropriate training
2


staff have demonstrated the skills required to support the person under the new
arrangements
Where a Guardian with the relevant authority has been appointed, he/she has
consented to the withdrawal of the practice.
2.2 Service Guidelines
The following service guidelines are to be considered when delivering services to people
who sometimes exhibit challenging behaviours. These guidelines are driven by the
assumption that people with disability are in the best position to make decisions and
choices for themselves and have the capacity to communicate these. Where people
display complex behaviours and before any consideration is given to the potential use of
a restrictive practice, this assumption must be confirmed.
2.2.1
Effective Service Design

Service providers will have policies, procedures and tools in place to
safeguard the rights of people with disability and monitor the use and
elimination of restrictive practices.

Effective service design starts with approaches that are person-centred and
proactive and that have enhancing the quality of life for the person as their
focus.

Service providers will adopt best practices that support and maximise the
person’s decision making, choice and self direction. The service provider is
responsible for ensuring that the person is giving informed consent in
relation to all matters that effect them and understands the nature and
consequences of their consent. This includes understanding the impact on
them of any prescribed restrictive practice that might result from their
consent.
2.2.2
Services providers will recognise that people with disability have the same rights
as all people to equality before the law and to equal protection under the law,
without discrimination.
2.2.3
The primary focus of services is to uphold human rights and the well-being,
inclusion, safety and the quality of life of people with disability.
2.2.4
Service providers will recognise that people with disability and their families and
carers are the natural authorities for their own lives and are in the best place to
communicate their choices and decisions.
2.2.5
Service providers will implement processes that recognise the person’s authority
in decision making, choice and control will guide the design and provision of
services.
3
2.2.6
Services providers will 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.
2.2.7
Service providers will recognise that the use of restrictive practices is not an
effective long term strategy to manage risks and behaviours and can result in
long term physical and psychological harm.
2.2.8
Service providers will actively facilitate the person’s engagement with family,
carers, other friends and advocates who know them well, are concerned for their
best interests and can support them in decision making, unless there is clear
evidence that the person does not consider this to be in their best interest.
2.2.9
Service providers will recognise that substantive equality is integral to the
service provision. Cultural relevance and appropriateness of services, in a
person-centred context, is an important consideration but does not over-ride the
requirement for the human rights of the person with disability to be the
paramount consideration.
2.2.10 Use of Restrictive Practices

Restrictive practices may only be implemented:
- with a prior review at a senior level in the organisation that confirms the
evidence that all less restrictive alternatives have been carefully
evaluated and cannot be applied
-
as a last resort, when the person presents a risk to themselves
and/or others
-
for the least time possible
-
with the informed consent of the person involved
-
after there has been an assessment of the impact of the practice
on the rights and well-being of others who share the person’s
environment
-
under the supervision of a designated, experienced staff member
who is on duty at the time
-
when contained in a clearly documented behaviour support plan
where a Guardian has been appointed with the relevant authority
and that s/he has consented.
4
2.2.11 Restrictive practices are not acceptable and cannot be approved for
organisational or staff convenience, or to overcome a lack of staff, inadequate
training, or a lack of staff support and/or supervision
2.2.12 Prescribed restrictive practices must be recorded at each event and reviewed by
the service provider at least every 12 months.
2.2.13 From time-to-time emergencies might occur in which an immediate and
otherwise unacceptable response might be required. Restrictive practices for
which there has been no prior prescription or consent, including seclusion and
physical restraint, may be used in an emergency to save a person's life or to
prevent them from experiencing serious physical or psychological harm, or to
prevent the person causing serious physical or psychological harm to another
person.
2.2.14 When a restrictive practice is used that has not been previously prescribed:

the circumstances in which the practice was used must be reviewed by the
service provider within seven days, to reduce the risk of a recurrence
and

must be reported to the Commission as a Serious Incident Report within
seven days.
2.2.15 Consent
 The service provider is responsible for ensuring that everyone involved in
supporting the person in these circumstances understands the nature and
consequences of the person’s consent. This includes understanding the
impact on them of any restrictive practice that might result from that consent.

The service provider will use whatever strategies are necessary to facilitate
the person’s capacity to communicate their choices and decisions.

When:
-
there is uncertainty about the person’s capacity to provide
informed consent
-
there is an absence of engaged family, carers, other friends and
advocates to assist the person to make decisions
-
there are conflicts around what decisions and actions are in the
person’s best interests
5
the service provider will seek the advice and guidance of the Office of the
Public Advocate for adults, and the Department for Child Protection for
children under 18 years of age, as to the appropriate action to take.
2.2.16 Use of a Therapeutic Device
The use of a therapeutic device does not constitute a restrictive practice when it is
clinically prescribed for the purpose of:

improving the quality of life of a person with disability, by preventing or
minimising body shape distortions and the directly related secondary
complications that result in pain, discomfort, and poor health
and/or

assisting a person to participate in a desired task or activity by minimising
factors which impede them, and enabling their engagement in an activity
which would not otherwise be possible
and/or

providing treatment1 for a person by preventing that person from injuring
themselves in cases where, if there were no restriction of the person, a
significantly adverse health outcome would occur.
A device may be used for these purposes if its use:

is clinically prescribed by an appropriately qualified health professional
such as a registered medical practitioner, occupational therapist, a
physiotherapist, a speech pathologist, a dentist, a podiatrist or an orthotist2

is formally and regularly reviewed

has the informed consent of the person or their representative 3 (in cases
where the person cannot give informed consent, service providers such as
allied health professionals have no authority under the Guardianship and
Administration Act 1990 to make a treatment decision, whether this is to
consent or withhold consent for treatment).
In the Guardianship and Administration Act 1990, the term “treatment” refers to any medical,
surgical or dental treatment or other health care, including life sustaining measures and palliative
care.
2 The definition of a “health professional” is a person registered under the “Health Practitioner
Regulation National Law (Western Australia)” as set out in the Civil Liability Act 2002,
Section 5PA. For list, see Appendix 2.
3 See Appendix 2 “Decisions About Treatment”.
1
6
The prescribed device must be the least restrictive alternative to achieve the desired
therapeutic result and be based on evidence from current best practice.
NB: The use of a device (eg arm splints) for the management of behaviour is however
considered to be a restrictive practice.
2.2.17 Use of Medication
The appropriate use of psychotropic and other drugs to reduce symptoms and
behaviours associated with conditions such as anxiety, depression and other mood
disorders or a psychosis, does not constitute a restrictive practice when:

the medication is prescribed for a person who has a psychiatric condition
diagnosed by a qualified psychiatrist and is reviewed at least annually
or

the medication is prescribed by a general practitioner who is treating the
person as part of a Medicare approved mental health plan and the
medication is reviewed at least annually.
2.2.18 Use of Environmental or Psycho-social Restraints
Whether or not an environmental restraint or a psycho-social restraint would be
considered to be a justifiable4 restrictive intervention for the purposes of this code of
practice requires the service provider to make a case-by-case decision which takes into
account:

the age of the person — some interventions might be restrictive in relation to
adults, but reflect broader, accepted community values and practices in
relation to the protection of children

whether the intent of the restriction is to punish or over-protect, or is to meet
a duty of care or an occupational health and safety requirement

the balance between the rights of the person and the rights of all others who
share the person’s environment.
Such practices, when prescribed, must be formally and regularly reviewed.
2.3
Code of practice review
In acknowledgement of the importance of the implementation of this code of practice,
the Commission will initiate a review no later than December 2013.
4
A justifiable restrictive practice is one that is implemented as per section 2.2.10.
7
For further information contact:
Jacki Hollick
Manager
Statewide Positive Behaviour Strategy
Statewide Specialist Services
Author:
Mike Cubbage
Manager
Behaviour Support Consultation Team
Statewide Specialist Services
Date: August 2012
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Appendix 1
International, National and State Obligations
The following have informed the development of the code of practice:

Universal Declaration of Human Rights

United Nations Convention on the Rights of Persons with Disabilities, with
particular reference to:
Article 4 1(b):
To take all appropriate measures, including legislation, to modify or abolish
existing laws, regulations, customs and practices that constitute
discrimination against persons with disabilities.
Article 4 1(c)
To take into account the protection and promotion of the human rights of
persons with disabilities in all policies and programs.
Article 4 1(d)
To refrain from engaging in any act that is inconsistent with the present
Convention and to ensure that public authorities and institutions act in
conformity with the present Convention.
Article 4 1 (e)
To take all appropriate measures to eliminate discrimination on the basis
of disability by any person, organisation or private enterprise.
Article 14
Liberty and Security of the person.
Article 15
Freedom from torture or cruel, inhuman and degrading treatment or
punishment.

Convention on the Rights of the Child 1990

Disability Discrimination Act 1992

Disability Services Act 1993

Children and Community Services Act 2004

Guardianship and Administration Act 1990
9

Equal Opportunity Act 1984 (WA)

Carers’ Recognition Act 2004

WA Disability Services Standards specified by the Disability Services Act 1993

Positive Behaviour Framework: Effective Service Design 2010.
10
Appendix 2
Definitions and Key Terms
There are various interpretations in the disability service sector of key terms associated
with the identification, reduction and elimination of restrictive practices, but the following
definitions are adopted for the purpose of this code of practice. The first five terms
defined below have been agreed at a national level by the Disability Policy & Research
Working Group (DPRWG), a standing committee of the Community and Disability
Services Ministers’ Advisory Council (CDSMAC).
Restrictive intervention
A “restrictive intervention” is any intervention and/or practice that is used to restrict the
rights or freedom of movement of a person with disability including:
Seclusion
“Seclusion” means the sole confinement of a person with disability in a room or
physical space at any hour of the day or night where voluntary exit is prevented.
Chemical restraint
A “chemical restraint” means the use of medication or chemical substance for the
primary purpose of controlling 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.
Mechanical restraint5
A “mechanical restraint” means the use of a device6 to prevent, restrict or subdue
a person’s movement or to control a person’s behaviour but does not include the
use of devices for therapeutic purposes.7
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 controlling a person’s behaviour. Physical restraint does not include
physical assistance or support related to duty of care or in activities of daily living.
Environmental restraint
An “environmental restraint” restricts a person’s free access to all parts of their
environment.
5
To be consistent with the international research evidence it is important to differentiate
mechanical vs physical restraints.
6 A device may include any mechanical material, appliance or equipment.
7 Therapeutic purposes may include, for example, safe travel such as seat belts during
transportation or arm splints as part of occupational therapy.
11
Examples of environmental restraints include, but are not limited to:
 barriers that prevent access to a kitchen, locked refrigerators, restriction of
access to personal items such as a TV in a person’s bedroom
 locks that are designed and placed so that a person has difficulty in accessing
or operating them
 restrictions to the person’s capacity to engage in social activities through not
providing the necessary supports that they require to do so.
Psycho-social restraint
“Psycho-social restraint” is the use of “power-control” strategies. Examples of
psycho-social restraints include but are not limited to:
 requiring a person to stay in one area of the house until told they can leave
 directing a person to stay in a unlocked room, corner of an area or stay in a
specific space until requested to leave (also known as “exclusionary time-out”)
 directing a person to remain in a particular physical position, (e.g. laying
down) until told to discontinue
 “over-correction” responses (e.g., requiring a person who has spilled coffee to
clean up not only the spilled coffee but the entire kitchen)
 ignoring
 withdrawing “privileges” or otherwise punishing, as a consequence of non
cooperation.
Therapeutic device
A “therapeutic device” is primarily used to improve function (motor and bodily) and to
prevent or reduce the risk of body shape distortion and their/its subsequent secondary
complications. Therapeutic devices employ a variety of methods used for the purpose of
restricting the movement of the person due to high or low tone and/or postural deformity
and in some instances behavioural movements. They may also be used for short
periods of time to allow for wound healing/tissue repair.
The use of a therapeutic device aims to minimise the person’s risk of developing
physical deformity/injury that leads to the development of pressure on the soft tissues, to
the development of pain or a reduction in functional capabilities.
Examples of therapeutic devices include, but are not limited to:







postural supports such as inserts
splints to minimise contractures
shoulder, chest, pelvic straps for optimal postural support
helmets
seatbelt modifications for safe transport
night time positioning equipment
sensory devices such as weighted blankets or vests.
12
Positive Behaviour Support (PBS)
Positive Behaviour Support (PBS) is a multi component intervention model that has
evolved from behavioural techniques and applied behaviour analysis.
The key identified components of PBS are: assessment-based interventions; reduction
of punishment approaches; inclusion of all relevant stakeholders; a long term-focus;
prevention through education, skill building, environmental redesign, enhanced
opportunities for choice, staff development, resource allocation, provision of incentives,
systems change; improved quality of life involving robust and significant person-centred
outcomes for the individual, their family and other stakeholders; ecological and social
validity and contextual fit.
Least Restrictive Alternative
The principle of least restrictive alternative recognises the right of a person to live in an
environment which is the most supportive and the least restrictive of his/her freedom 8.
In the context of the use of a restrictive practice it requires that service providers engage
in actions that:
a) ensure the safety and well-being of the person and all others who share their
environment
b)
having regard to (a) above, impose the minimum limits on the
freedom of the person as is practicable in the circumstances.
Informed Consent
The notion of “informed consent” requires careful and special consideration, and must
always be assessed on a case-by-case basis.
Informed consent means a person:



is provided with appropriate and adequate information
is capable of understanding the nature of the information and the
consequences of a decision made in relation to this information
can freely decide for him or herself without unfair pressure or influence from
others.
In obtaining informed consent, the service provider must consider the following:


Information might need to be provided in different ways depending on the
person’s disability, needs and mental state at the time.
What the consent applies to must be very clear. For example, with regard to
sharing of information, the person should be informed about what information
will be shared, with whom and how. Care should be taken to avoid
assumptions that consent provides a blanket approval, or that consent on one
occasion or about one event implies consent for future occasions or events.
8
Parliamentary White Paper on Services for People with Intellectual Disability in Queensland
(1988) cited in www.cmc.qld.gov.au/.../report-of-an-inquiry-into-allegations-of-officialmisconduct-at-the-basil-stafford-centre-part-3”
13
The person should be informed that they have the right to change/retract their consent.
Failure to observe the requirements necessary for informed consent to be obtained can
result in the infringement of a person’s rights.
Decisions about treatment9
Under the Guardianship and Administration Act 1990, the term “treatment” refers
to any medical, surgical or dental treatment or other health care, including lifesustaining measures and palliative care.
Under the same act a “treatment decision” is defined as a decision to consent or
refuse consent to the commencement or continuation of any treatment for the
person.
In cases where decisions are required about a course of treatment for an adult
who is not capable of making reasoned decisions, the Guardianship and
Administration Act 1990 allows for substitute decision makers to be appointed by
the State Administrative Tribunal. A person thus appointed to make personal,
lifestyle and treatment decisions is known as a guardian. To protect a person’s
decision making rights wherever possible, a guardian will be appointed only if it is
considered necessary to safeguard the best interests of a person aged 18 years
or older, whose decision making capacity is impaired and if other less restrictive
options are not available or appropriate.
Process for obtaining a treatment decision
All decisions regarding children should be made by their legal guardians. In the
case of adults, the Guardianship and Administration Act 1990 specifies a
procedure to be followed when treating a person aged 18 years or over who is
incapable of making a treatment decision due to a decision making disability.
The request for consent for treatment must be sought from a hierarchy of
decision makers who themselves are adults (18 years or older), have full legal
capacity, are reasonably available and are willing to make the decision.
Hierarchy of treatment Decision makers is set out under the Guardian and
Administration Act 1990, Section 110ZD and Section 110ZJ:
Office of the Public Advocate, “Position Statement. Decisions about treatment”, Government of
Western Australia, Department of the Attorney General.
9
14
Advance Health Directive (AHD)
Decisions must be made in accordance with the
AHD unless circumstances have changed or
could not have been foreseen by the maker.
Where an AHD does
not exist or does not
cover the treatment
decision required, the
health professional
must obtain a decision
for non-urgent
treatment from the first
person in the hierarchy
who is 18 years of age
or older, has full legal
capacity and is willing
and available to make
a decision.
Enduring Guardian with authority
Guardian with authority
Spouse or de factor partner
Adult son or daughter
Parent
Sibling
Primary unpaid caregiver
Other person with close personal relationship
If none of the above are reasonably available or willing to make the decision, a
guardian may need to be appointed. In situations where the decision making
process is unclear it is best to seek the advice of the Office of the Public
Advocate (contact details provided at the end of this document).
Health Professional
Civil Liability Act 2002, Section 5PA
5PA. Term used: health professional
“health professional” means—
(a)
a person registered under the Health Practitioner Regulation National Law
(Western Australia) in any of the following health professions —
(i)
chiropractic
(ii)
dental
15
(iii)
(iv)
(v)
(vi)
(vii)
(viii)
(ix)
(x)
medical
nursing and midwifery
optometry
osteopathy
pharmacy
physiotherapy
podiatry
psychology
or
(b)
any of the following —
(i)
a medical radiation technologist as defined in the Medical Radiation
Technologists Act 2006 section 3
(ii)
an occupational therapist as defined in the Occupational Therapists
Act 2005 section 3
(iii)
any other person who practises a discipline or profession in the
health area that involves the application of a body of learning.
Substantive Equality
Substantive equality recognises that:



rights, entitlements, opportunities and access are not necessarily distributed
equally throughout society
equal or the same application of rules to unequal groups can have unequal
results
where service delivery agencies cater to the dominant, majority group, then
people who are not part of the majority group and who have different needs
might miss out on essential services.
Hence, it may be necessary to provide different service types and approaches to people
with disability and their families who are members of minority groups.
Disability Services Commission Substantive Equality
Statement of Commitment for People with Disabilities
February 2006
For Further Information on Substitute Decision Making For Adults Contact:
Office of the Public Advocate
Level 1, 30 Terrace Road, East Perth WA 6004
PO Box 6293, East Perth WA 6892
Telephone:1300 858 455
Facsimile: (08) 9278 7333
Email: opa@justice.wa.gov.au
Web: www.publicadvocate.wa.gov.au
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