Restrictive Practices Guidance Physical Restraint

Key Points

If the person uses behaviours of concern, a functional behavioural assessment must be completed, regardless of whether chemical restraint is used.
Workers using physical restraint must be appropriately trained and physically capable of using the strategy safely.
If the person has difficulty communicating, then a communication assessment will help find strategies the person could use to communicate their issues.
Under no circumstances should direct pressure be applied to the neck, thorax, abdomen, back or pelvic area of a person when using physical restraint.
If you are unsure whether a practice is physical restraint or not, seek advice.

Introduction to physical restraint

A physical restraint involves 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. It 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.

Physical restraint can only be applied when other less intrusive strategies have been tried, and as a planned response to behaviours of concern. Physical restraint can cause negative physical and psychological outcomes for both the person being restrained and workers applying physical restraint. Harm associated with the use of physical restraint can include pain, pressure injuries, and even death. Estimates of the prevalence of physical restraint being used with people using behaviours of concern vary widely, from as high as 100% to as low as 3%. From July 1 2020 to June 30 2021, there were 1,060 reported instances of unauthorised use of physical restraint in NSW (NDIS Commission 12-monthly activity report: July 2020 - June 2021).

A restrictive practice is an intervention which has the effect of restricting the rights, freedom of movement, or access of a person with a disability who is displaying a behaviour of concern.

Restrictive practices should be used only in limited circumstances as a last resort and not as a first response to behaviours of concern, or as a substitute for adequate supervision. We are working towards the reduction and elimination of the use of restrictive practices.

Restrictive Practices Include:

Seclusion
Physical Restraint
Mechanical Restraint
Chemical Restraint
Environmental Restraint

The NSW Government oversees authorisation of restrictive practices by registered NDIS providers. The NDIS Quality and Safeguards Commission provides leadership in behaviour support and in the reduction and elimination of restrictive practices.

Do I need authorisation to provide any or all kinds of physical support or guidance?

Authorisation is not required for non-coercive physical assistance or support to enable activities of daily living or for therapeutic purposes. This is distinct from physical restraint, which restricts or subdues the movement of a person for the primary purpose of behavioural control.

Physical assistance or support to enable activities of daily living may include physically assisting a person to dress, shave, or brush their teeth, where the physical contact is non-coercive. It may also include helping people to learn new skills, such as physically guiding a person’s hand to use a tool such as a knife for preparing food.

Physical assistance or support for therapeutic purposes by a worker such as a physical or occupational therapist may include providing physical support or resistance to assist a person to stretch or exercise a muscle. Hands-on techniques for postural support or to assist a person to develop a new skill are also not usually considered to be restrictive practices and do not require authorisation.

Physically guiding or redirecting a person away from potential harm or injury, such as by moving their hand away from a hot plate or holding a person’s hand when crossing the road is not defined as a restrictive practice. This kind of support is reasonably consistent with the exercise of care towards a person and does not require authorisation. It is also okay to physically guide a person to ensure their safety, such as guiding a person away from the road.

What issues do I need to consider for participants when using physical restraint?

Physical restraint should not be used without consent. For consent to be valid it must be voluntary, informed, specific and current.

Where possible, consent should be obtained from the person if they are an adult or young person (16-18 years). Consent may also be given by other people, such as a guardian with a restrictive practices function, including a person appointed by the Guardianship Division of the NSW Civil and Administrative Tribunal. Consent for the use of a regulated restrictive practice for a child should be obtained from a parent or guardian, or the person with parental responsibility (e.g. the Minister for Families and Communities).

Some characteristics of a person can increase the risks of using physical restraint strategies with that person. Examples include the person’s general physical health, weight, specific conditions such as Down and Turner syndrome, medications that may affect heart function, and neurological or psychological factors. If the person has any of these characteristics, particular care should be taken to avoid physical restraint, and to ensure that the person is safe if physical restraint strategies are used. The use of physical restraint should carefully consider the needs of the individual, such as their gender, culture, and instances of past trauma.

The effects of physical restraint on people being restrained are often negative and care must be taken to minimise risk of injury. These forms of physical restraint are prohibited:

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.

What limitations apply to the use of physical restraint with children and young persons?

The law limits the extent to which physical restraint can be used with a child or young person, as well as requirements that must be met for an agency to use physical restraint with a child or young person in its care.

Section 158 of the Children and Young Persons (Care and Protection) Act 1998 outlines where physical restraint can be used with children and young persons, stating that a guardian or person authorised with consent may restrain the child or young person, but only on a temporary basis and only to the extent necessary to prevent injury to any person, or seize and take from the child or young person:

Any weapon or other thing that is being used in a dangerous manner;
Any alcohol;
Any illegal substance;
Any other thing necessary to prevent the child or young person from causing injury to any person.

Section 45 of the Children and Young Persons (Care and Protection) Regulation 2012 identifies requirements in a behaviour management policy statement that sets out behaviour management practices for the care, management and discipline of children and young persons, details of the procedures to be used, including consent, reporting, analysis and supervision of staff, and support and counselling to be provided to children and young persons to whom physical restraint has been applied. Evidence that the child or young person has received support and/or counselling in relation to each instance must be included with an application for authorisation to use physical restraint with a child or young person.

What less restrictive alternatives to physical restraint should I consider?

A range of positive behaviour support strategies may assist a person to manage behaviours of concern without the need for physical restraint. This may include environmental supports that can influence the person’s behaviour and help them to learn new behaviours without infringing on their rights.

Low-arousal techniques may assist in managing behaviours of concern, such as by minimising the frequency, complexity and duration of expectations of the person. De- escalation techniques and mindfulness training may also be beneficial, for both the people with a disability and support workers.

Room-based interventions, such as sensory rooms, relaxation rooms, and safe or comfort rooms may be effective for some people. Similarly, sensory interventions, including preferred sensory stimulation, may help some people to manage behaviours of concern without the need for physical restraint.

Behaviour support interventions that are consistent with functional assessment are more effective in managing behaviours of concern. For example, some people who are distressed when routines change can benefit from help to prepare for changes of plan so that they are less distressed. All behaviour support plans need to be based on a functional behaviour assessment so that strategies can address the purposes of the behaviour.

What duty of care issues should I consider when using physical restraint?

Anyone for whom a physical restraint is recommended or used should have a functional behaviour assessment to identify appropriate environmental, personal, and social supports.

Physical restraint may cause or contribute to injury or discomfort for the person, especially if the person is agitated and resisting. When deciding whether to authorise the use of a restrictive practice for a person in a specific setting, an RPA Panel will consider whether the organisation has the capacity to apply the strategy to that person safely, e.g. if a strategy requires two workers to physically restrain the person, the Panel will consider whether two suitably trained workers will be available to restrain the person when required. In circumstances where it is not possible to apply the strategy appropriately and without unacceptable risk of injury to the person, alternative strategies may be necessary.

A person who is subject to physical restraint should be monitored closely for the duration of the restraint and be reviewed medically after the restraint if there is a possibility that the person was injured.

Using physical restraint may also cause or contribute to injury or discomfort for workers applying the strategy. Workers using physical restraint should be appropriately trained to use the strategy safely and should have the necessary physical capacity to apply the restraint as intended. Alternative strategies may be necessary in circumstances where the workers available to apply physical restraint are not able to use that restraint safely, e.g. where the worker or workers are not capable of physically restraining the person.