Much Needed Clarity from the Commission

The NDIS Quality & Safeguards Commission (NDIS Commission) recently released the Regulated Restrictive Practices Guide V1 – October 2020 (RP Guide).

This is a welcome document from the NDIS Commission as it provides the much-needed clarity on previously grey areas of policy and practice.

The scope of the RP Guide states that it “was developed for registered NDIS providers and NDIS behaviour support practitioners supporting NDIS participants, but it may also be of interest to anyone who supports a person with disability.” We think they are right on the money – the RP guide will be useful for the participants themselves, families and carers, GPs and psychiatrists, and many others.

So what does it cover? On the face of it, not a lot of new things, as the NDIS Commission has well established its position on restrictive practices – the commitment to reduction and elimination, the implementation of practices only once they have been authorised, the focus on regular monitoring, reporting and review and the provision of restrictive practices within the context of a positive behaviour support framework. It’s the detail behind it that grabbed our attention!

The RP guide provides additional guidance and further clarity to support the restrictive practice definitions. Much of this additional information already exists in places such as the Practice Standards, legislation and other documents released by the NDIS Commission, as well as in the information on restrictive practices issued by States and Territories. However, explicitly including this information in a single document facilitates enhanced clarity, consistency of practice and, ultimately, high-quality supports and services to people with disability to improve their quality of life. Who can argue with that?

Chemical restraint

This refers to “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 disorder, a physical illness or a physical condition.”

Additional guidance includes:

•  The use of medication to support a pre-medical appointment, wherein a person is prescribed medication for anxiety or agitation, and this is administered prior to a medical or dental appointment. The purpose of this mediation is to “enable treatment of a diagnosed mental ill health, a physical illness or a physical condition” and is, therefore, not considered a chemical restraint. 
•  Medication for menstrual management is not considered a chemical restraint when:
  • Prescribed for a diagnosed medical condition
  • Given at the request and with the consent of the person with a disability 

Environmental restraint

“Restricts a person’s free access to all parts of their environment, including items or activities.”

What the RP Guide tells us here is that we need to think about any of our practices that are beyond ordinary community standards for the purpose of managing a behaviour of concern that can cause harm to persons with disability and/or others. This means that we don’t need to worry about locking the front door of a house at night (that’s a fairly long-standing community practice), as long as the person is still able to leave home if they choose to.

The RP Guide also directs us towards the Practice Standards for Management of Medication, reminding us that the standards require medications to be stored safely and securely. As such, providers are not required to report the locking of medication to the NDIS Commission. However, medication administration needs to be person-centred, so building the capacity to self-manage medications should be encouraged when appropriate. 

There is also an acknowledgment that some environmental restraint practices can have an impact on others who share the same environment. The RP Guide cautions providers about “communal ripple effects”on the human rights of others sharing a service or residence. Providers are recommended to take steps to curtail the impact of a restrictive practice on other people using the service.

Mechanical retraint

“The use of a device to prevent, restrict or subdue a person’s movement for the primary purpose of influencing a person’s behaviour, but does not include the use of devices for therapeutic or non-behavioural purpose.”

The RP Guide clarifies that:

•  Devices for therapeutic and non-behavioural purposes are defined as devices that assist a person with everyday functional activities or help their injuries heal(Department of Health and Human Services 2019) and mechanical restraint and therapeutic/non behavioural devices are distinguished by the reason why they are being used
• Therapeutic devices can only be prescribed by an appropriately qualified health professional (such as a registered medical practitioner, occupational therapist, physiotherapist, speech pathologist, dentist, podiatrist, assistive technology technician, exercise physiologist or orthotist) 
• Any mechanical restraint intended to cause harm to a person with disability is considered abuse

Physical restraint

“The use of action or physical force to prevent, restrict or subdue movement of a person’s body, or part of their body, for the primary purpose of influencing their behaviour. Physical restraint does not include the use of a hands-on technique in a reflexive way to guide or redirect a person away from potential harm/injury, consistent with what could reasonably be considered the exercise of care towards a person.” 

The RP Guide indicates that reasonable safety measures and practices that are used to assist a person with daily living and therapeutic activities are not physical restraints if the person is unable to complete the task safely and by himself/herself. However the level of force used can turn a practice into a physical restraint and that physical assistance should not be coercive.

The RP Guide explicitly enumerates a range of practices that are prohibited in relation to all NDIS participants, as they are associated with high risks of injury and death. These are the following:

• Prone restraint (subduing a person by forcing them into a face-down position)
• Supine restraint (subduing a person by forcing them into a face-up position)
• Pin downs (subduing a person by holding down their limbs or any part of the body, such as their arms or legs)
• Basket holds (subduing a person by wrapping your arm/s around their upper and or lower body)
• Takedown techniques (subduing a person by forcing them to free fall to the floor or by forcing them to fall to the floor with support)
• Any physical restraint that has the purpose or effect of restraining or inhibiting a person’s respiratory or digestive functioning
• Any physical restraint that pushes a person’s head forward onto their chest
• Any physical restraint that compels a person’s compliance by inflicting pain, hyperextending joints, or applying pressure to the chest or joints (Department of Health and Human Services, 2011)

Seclusion

“Sole confinement of a person with disability in a room or a physical space at any hour of the day or night where voluntary exit is prevented or not facilitated, or it is implied that voluntary exit is not permitted.”

The RP Guide provides further guidance on the following:

Examples of instances of seclusion:

• A person is told they cannot leave their room until they calm down. If the person believes they cannot leave the room, this is seclusion.
• Another example they give is: ‘Staff and other residents retreating to an office/ secure room/ backyard while the person is restricted to the remainder of the house and is unable to leave, or believesthey are unable to leave.’ 

Examples of instances that do not constitute seclusion:

•  A person locking their room or bathroom door for privacy while being able to leave at any time 
• A person home alone choosing to lock the front door while being able to leave at any time

For each of the regulated restrictive practices, the RP Guide also offers a wealth of other information and resources to support decision making. These include:

•  Decision trees to help NDIS providers determine if a particular practice is considered restrictive
• Possible impacts of using each type of restrictive practice, who is most at risk and the important considerations
• Case studies and examples
• Links to additional resources 

The National Framework for Reducing and Eliminating the Use of Restrictive Practices in the Disability Service Sector challenges us all to work in ways that promote a person’s quality of life to reduce and eliminate the need for restrictive practices. The Restrictive Practices Guide is a welcome document that supports high-quality decision making and practices to enhance the quality of care and safeguarding of people who are subject to restrictive practices.