A nurse is creating a plan of care for a client who has been placed in seclusion

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
• environmental restraint
• mechanical restraint
• physical restraint
• seclusion.

Minimising inappropriate use of restrictive practices

In January 2019, an Aged Care Clinical Advisory Committee was set up. Its role is to advise on ways to reduce inappropriate use of chemical restraint in residential aged care.

Initiatives to minimise inappropriate use of restrictive practices include:

• strengthening laws that apply to residential aged care providers on restrictive practice use
• changes to the Pharmaceutical Benefits Scheme (PBS) risperidone listing
• awareness raising activities on the appropriate use of antipsychotics and benzodiazepines in residential aged care.

Why this is important

Residential aged care providers must provide our senior Australians the safe and quality care they deserve.

Reducing the inappropriate use of restrictive practices is part of providing quality care.

Laws on minimising restrictive practices

Amendments to the Aged Care Act 1997 that regulate and strengthen restrictive practice arrangements for approved residential aged care providers took effect on 1 July 2021.

These amendments aimed to:

• improve safeguards for care recipients
• place an increased responsibility on residential aged care providers.

The Quality of Care Principles 2014 were revised to provide details for approved providers on how to comply with the law.

The strengthened responsibilities on the use of any restrictive practice in a residential aged care setting included consent requirements and the introduction of a restrictive practice substitute decision-maker.

Recent Developments

To support providers in some jurisdictions where there is no legal framework to allow for a restrictive practice substitute decision-maker, further amendments to the Aged Care Act 1997 have been made through the Aged Care and Other Legislation Amendment (Royal Commission Response) Act 2022 (Act).

The Act supports interim arrangements for a restrictive practice substitute decision-maker in states and territories where the laws do not clearly allow a person to consent to restrictive practices.

The Department is finalising the subordinate legislation (Quality of Care Amendment (Restrictive Practices) Principles 2022) that will allow persons or bodies that are authorised to provide informed consent to the use of restrictive practices.

This hierarchy will only apply if the care recipient lacks capacity to give consent and the relevant state or territory laws do not allow any individual or body to have this authority.

Publication of the exposure draft and explanatory statement

The Department published an exposure draft and explanatory statement of the Quality of Care Amendment (Restrictive Practices) Principles 2022, which was available for review for 14 days.

The Department is no longer seeking feedback on the draft legislation. Comments provided during the consultation period will be considered when finalising the Principles and when considering a restrictive practice substitute decision-maker in the new Aged Care Act.

Further information

If you have any questions about the existing or proposed legislative requirements, please contact us.

The Aged Care Quality and Safety Commission website has additional information to support providers to meet their requirements around restrictive practices.

Provider responsibilities

Providers must consider the rights and protection of care recipients at all times.

From 1 July 2021, approved residential aged care providers  must comply with legislative obligations. Approved providers using a restrictive practice must make sure:

• to use it as a last resort to prevent harm to a care recipient or others, and after considering how it may impact the care recipient
• to trial and document alternative strategies before considering a restrictive practice
• to use it in the least restrictive form and for the shortest time needed
• the care recipient or the restrictive practices substitute decision-maker gives informed consent for the use of the practice
• to only use it in line with the rights and responsibilities of care recipients outlined in the Charter of Rights
• to monitor and regularly review its use.

From 1 September 2021, you must include a Behaviour Support Plan (BSP) in the existing Care and Services Plan for all care recipients:

• that demonstrate behaviours of concern
• being assessed to see if a restrictive practice is needed
• where a restrictive practice is being used.

Medical and nurse practitioners

Like aged care providers, general practitioners (GPs) working with care recipients (patients) must consider and protect their patients’ safety and wellbeing at all times.

Only use restrictive practices as a last resort, to prevent harm to the patient and those around them. As a practitioner you must use and document alternative strategies to manage the patient before using a restrictive practice.

Before using psychotropic medication, you must trial and document other strategies in the patient’s clinical record. We have guidance material to:

In order for an aged care provider to use a restrictive practice that is chemical restraint a medical practitioner must have:

• assessed the patient as posing a risk of harm to themselves or others
• assessed that the chemical restraint is necessary as a last resort
• discussed the proposed benefit, options, and risks of the medication with the person or their substitute decision maker and seek their informed consent
• conveyed the fact that informed consent has been received for the prescribing of the medication to the provider in an agreed way
• prescribed the medication.

As a medical practitioner, an aged care provider may ask you to perform the above tasks and provide evidence in order for them to use a restrictive practice. The aged care provider will then document this in the patient’s behaviour support plan.

How you as a practitioner can help

Practitioners perform an essential role in the care of residential aged care recipients (patients) and in minimising the inappropriate use of restrictive practices.

There are many ways that practitioners can help providers to meet their requirements and make sure patients are safe and well.

• Check for any contribution of current medication to confusion, sedation or other side effects potentially causing distress or behaviours of concern.
• Identify and document the risk of harm to self or others that medication used as restraint seeks to address.
• Communicate the decision to prescribe medication with the aged care provider and relevant staff.
• Seek informed consent from the appropriate person and communicate this consent with the provider.
• Outline the monitoring required for side effects that might occur.
• Clarify the need for ongoing review of effectiveness and impact and when this will occur.
• Clearly state the conditions when ‘as needed’ (PRN) sedating medication may be used.
• Regularly review medications, especially psychotropics, so that deprescribing can occur as early as possible.
• Communicate with other current or past prescribers where indications for their prescribing and responsibilities for review are not clear.

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:

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 Commission’s Better Use of medication in aged care Program to 2025.

Education and training

We have developed educational fact sheets to help the sector understand restrictive practices, their use in residential aged care and the rules around informed consent.

The Aged Care Quality and Safety Commission also has more information to support providers.

Who we work with

The Aged Care Quality and Safety Commission’s 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 provider’s compliance with the restrictive practice requirements. These include having:

• a Behaviour Support Plan (BSP) 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.

Related information

The Aged Care Quality and Safety Commission has:

There are also further resources available through the following organisations:

• Dementia Support Australia (DSA) provides support for people living with dementia who are experiencing changes in behaviour that impact their care or carer. Services include the Dementia Behaviour Management Advisory Service (DBMAS) and Severe Behaviour Response Teams (SBRT).
• Dementia Training Australia (DTA) provides free online dementia training, practical resources and training packages. DTA also provides face-to-face training to providers and the sector. These resources help staff better understand the causes of behaviour change and to find ways to avoid or reduce them.

Resources

For more information, see:

Contacts