Definitions of Bodily and Mechanical Restraint, Seclusion

Discuss About The Journal Research Intellectual Disabilities.

Restrictive intervention refers to the usage of mechanical or physical (bodily) form of restraint and seclusion (health.vic.gov.au, 2018). Bodily restraint can be defined as a form of mechanical or physical restraint that inhibits free movement of an individual, and does not include the use of furniture that inhibits the ability of an individual to get off it. Physical restraint includes the use of physical restriction or hands on immobilization, while mechanical restraint includes the use of equipments in order to limit the locomotion of an individual. Seclusion is the act of solitary confinement of an individual in an enclosed space like a cell or room, and the individual does not have the liberty to leave on their free will (health.vic.gov.au, 2018; Webber et al., 2011; Foss, 2016; Brophy et al., 2016).

Restrictive practices are used by caregivers and service providers and limit the freedom or rights of locomotion of individuals with disability, the intention is to protect the individual or others around them from any harm (Nurjannah et al., 2015). Such interventions are applicable for individuals who display challenging or concerning behaviour, and used in a different environments such as: group homes, supported accommodation centres, residential facilities, mental health facilities, rehabilitation facilities, prisons, hospitals and schools (Alrc.gov.au, 2018). However, there exist significant concerns regarding the use of restrictive intervention as a form of coercion, disciplining, convenience or even retaliation by staff/family members or other caregivers (Alrc.gov.au, 2018; Rose et al., 2017; Brophy et al., 2016; Cleary et al., 2015).

Studies have shown that use of restrictive interventions can have adverse effects on the residents. Duke et al. (2014) studied the usage of restrictive interventions on children as well as adolescents in a psychiatric inpatient centre in Australia, and found that such interventions were related to the incidence of physical aggression. Mohr et al. (2003) suggested several adverse effects of using restraints like: restraint asphyxiation, blunt trauma to chest, accidental asphyxiation, catecholamine rush, adverse effects of psychotropic medications, rhabdomyolosis, thrombosis, adverse psychological effects (traumatic emotional response, rage, anxiety, fear, intrusive thoughts, avoidance response, increased startle response and mistrust on mental health professionals.

Victoria’s Mental Health Act 2014 puts focus on the individuals with mental health disorders and places them at the core of the decision making process regarding their care and treatment. It fosters the development of strong relationships between practitioners and those using the service, and provides information and support and assists them in order to make informed choices. It also fosters the philosophy of supported decision making through effective communication between the practitioners, patients and their families or caregivers. It fosters the development of an understanding and respect towards the preferences and views of the individuals with mental health conditions and allows them to participate in the decisions related to their treatment (health.vic.gov.au, 2018).

• Using the least restrictive and intrusive way for the assessment and treatment of mental health conditions
• Supporting individuals to participate in the decisions related to their assessment, treatment and recovery
• Protection and promotion of individual rights, autonomy and dignity
• Provision of holistic care and support that focuses on the individual needs of the patients
• Prioritizing the protection of children’s wellbeing and safety
• Recognition and support given to the caregivers in participating in the decisions on care and treatment of the patients (health.vic.gov.au, 2018).

Types of Facilities where Restrictive Intervention is Used

The act provides specific guidelines that incorporate the core values of the mental health act. These guidelines are related to: recovery and supported decision making, compulsory treatment, safeguards, oversight and service improvement, (health.vic.gov.au, 2018).

Recovery and supported decision making model is designed to support compulsory patients to make and participate in decisions regarding treatment and decide their individual recovery paths (Watson, 2017; Carter & Chesterman, 2009). The model provides a legislative framework supporting the recovery oriented practices in mental health services. The model includes several components like Mental Health Principles, Advance Statements, Advocacy, Informed Consent, Nominated Persons, and Presumption of capacity and Second Opinions (health.vic.gov.au, 2018).

Mental Health Principles which recommends the use of the least restrictive form of treatment and the availability of voluntary assessment or treatment for the patient; aim to bring about the best therapeutic outcomes; ensuring the rights, dignity or autonomy of the patients are respected and promoted and the best interest of the patients should be recognized in the treatment. It also supports the participation of the patients, their families and caregivers in the decisions related to treatment. Advance Statements are statements that are written by an individual that expresses the type of treatment they would like to receive if they develop a mental health condition that requires treatment. Advocacy is a crucial component of the supported decision making process, and mental health advocates support the individuals to take and participate in their decisions about the assessment, treatment as well as recovery and assist them comprehend and utilise their legal rights. Informed Consent is also needed from the individuals before treatment is started, and requires the circumstances and the process of the treatment must be clearly outlined. The patient can also nominate a person who will be given information and support in the occasion they develop mental health condition and require compulsory mental health treatment. Patients can also opt for second opinions in order to better understand and make decisions regarding their treatment. These aspects can help the patients and their families or caregivers to make decisions on the least restrictive ways of treatment (health.vic.gov.au, 2018).

For restrictive Interventions, the regulation is provided by the Mental Health Act, and is aimed to reduce and even eliminate the need of using such strategies. The act mandates that restrictive interventions be authorized by either an authorized psychiatrist or a registered medical practitioner (if a psychiatrist service is not available). If restraining intervention is used by the registered medical practitioner or senior registered nurse, it must be notified to the authorized psychiatrist or a delegate, after which the individual needs to be examined as soon as possible to determine the continuation of restrictive interventions. Urgent physical restrains are to be used only when there is an imminent and serious harm can befall the patient, if the authorized professional is not immediately available or to administer medication or treatment. Rrestrictive intervention should be considered only after all the possible less restrictive approaches have been tried and found to be unsuitable and the individual should be released as soon as the reasons for using restrictive intervention stops being applicable. Urgent restraints should be used for the minimum period to prevent imminent or serious harm to the patient or others, or to seek necessary authorization from the designated professional. Notification should also be given to the nominated person, guardian, career of the patient, as well as the Secretary of the Department of Human Services (or a delegate). This ensures that physical restraints are only used when no other options are available, and whenever used, should be restricted to the shortest amount of time, followed by a quick notification to be sent to the relevant authorities and benefactors. The act also provides safeguards for the patients in the form of high levels of clinical care, reporting and monitoring with the usage of restrictive interventions. This also increases the responsibility of the psychiatrist to oversee the continuation of restrictive interventions. After using a restrictive intervention, the medical practitioner or registered nurse should review the use of body restraint or observe the effect of seclusion, clinically, at least every 15 minutes, while an authorized psychiatrist or delegate should examine the patient at least once every four hours. A written report to the chief psychiatrist should also be prepared by the psychiatrist. Additionally, a statement of rights must be provided to patients during key stages of the assessment and treatment, and include information like the point of legal contact, application to mental health tribunal, choosing a nominate person, how to make complaints to Mental Health Complaints Commissioner, legal representation of the patient and their caregiver and providing assistance of community visitors (health.vic.gov.au, 2018).

Adverse Effects of Restrictive Interventions on Patients

The framework of ‘Providing a safe environment for all’ is aimed to assist mental health services as well as professionals to design or plan services that can reduce and is possible even eliminate the usage of restrictive interventions on patients with mental health conditions. The framework suggests the reduction of restrictive practices like seclusion or restraints in mental health services  while ensuring safety to all consumers (of the service), health staff and visitors, and using restrains only when other less restricting options have been used and found unsuitable to protect the wellbeing of the users of the service (health.vic.gov.au, 2018).

• Respect and dignity of the consumers and their support network and health staff
• Showing decency, humanity and respect to individual rights while managing challenging or difficult behaviour
• Using restrictive intervention as the last resort and only after trying other, less restrictive forms of interventions, and found to be unsuitable in the given circumstance
• Utilizing supported decision making, trauma-informed care and recovery oriented practice to inform all workplace practices
• Provision of effective governance and continued monitoring of local action plan to ensure effective implementation of programs that aim to reduce restrictive interventions (health.vic.gov.au, 2018).

The ‘providing safe environment for all’ includes ‘snapshots’ of good and effective practices as well as necessary guidelines that are useful to support planning, decision making, review and quality assurance of mental health services. The framework also contains reflective practices that can be helpful to the managers as well as healthcare workers in the assessment of their own practice, and allow the identification of strengths and weaknesses of their system and capacities and be used to plan local responses that can lower their dependency on restrictive practices (health.vic.gov.au, 2018).  The importance of safe environment is highlighted by the studies by Daykin et al. (2008) that showed how the design of the environment can affect the mental health of patients as well as staff in a mental health institute.

• Internal assessments on the use of three care practices: supported decision making, trauma-informed care and recovery oriented practice and also create a change management strategy informed by the framework
• Development of a workforce plan that contains alternative strategies in the management of aggressive behaviour and guidelines for to help other in the process
• Review on how the data is utilized to inform practical and monitoring process
• Fostering the development of a culture of enquiry and learning through reviews of the governance structures and outline clearly the various roles and responsibilities
• Development of programs of activities that can reduce the use of restrictive interventions and foster the involvement of service users and caregivers to ensure the activities are based on practical contexts and real life experience.
• Adapting the policies and processes to be included in the reflective process and critical reviews of situations as they occur (health.vic.gov.au, 2018).

The framework also recommends several capabilities which can help the implementation of the framework.

Effective leadership can play a crucial role to influence and inspire others and work towards a common objective of reducing the use of restrictive interventions (health.vic.gov.au, 2018; Gopee & Galloway, 2017; Cooper, 2015; Delmatoff & Lazarus, 2014). It is important therefore to create an organizational environment that supports the staff in the change process while the leaders should be able to advocate, manage and facilitate the process of change (Cai et al. 2016). Accountability should also be at the core of such principle that ensures a clear sense of responsibility to reduce restrictive interventions (World Health Organization, 2014). Furthermore, leadership can be managerial, clinical or cultural, and not restricted to only managers or certain positions, but dispersed organization-wide including individuals with livid experience, staff and caregivers (health.vic.gov.au, 2018).

The ability of self determination of the patients can be facilitated by helping the development of an environment that values lived experiences as well as acknowledges past trauma and provides support to people to expresses their needs. This can be possible through eh acknowledgement of the rights of individuals with lived experiences in the decisions related to their care (Moran et al., 2014). This aspect highlights the use of recovery oriented practice with emphasis on hope, community participation, social inclusion, self management and personal objective settings. The approach can be directed towards supported decision making process and understanding the expressed wishes of individuals. The capability is based on the assumption of capacity of decision making by the patient, and information or support is provided to facilitate the decision making. It also involves the services being aware and responsive to the needs of the patients (health.vic.gov.au, 2018; Sowers & Swank, 2017).

Guidelines Provided by Victoria’s Mental Health Act 2014 to Reduce and Eliminate Use of Restrictive Interventions

It is also vital to have a capable and skilled workforce to develop a culture where restrictive interventions are used as the last option. Workforce should be invested to support the least restrictive interventions and all staff should be oriented towards the objective of reducing such practices. It is necessary to recognize the workforce as an interdisciplinary team while developing organizational capacity towards a positive work culture (Margolis et al. 2018). Partnership approach can also help to instil a sense of accountability, flexibility, responsibility and support self determination (Scutchfield et al., 2016). It is vital therefore to build healthy team work, supported through skilled workforce that focuses on competency and commitment. Important job roles must also be clearly defined. The effect of trauma on people with lived experiences should be recognized by the staff (health.vic.gov.au, 2018)

Health service systems are a combination of an organization of people, resources and processes of care delivery. The system also involves policies, care models, external and internal environments and a complex interplay between these components which governs the process of delivery of care. It is important for the healthcare systems to align completely with the vision to lower or remove the use of restrictive interventions. The policies and procedures offers clear directions and guidance on how to prevent or manage escalations and help individuals with lived experience and their support staff to work together. Informed by the best practices, a system can be responsive to the local service environment. It is also possible to collaborate the design of therapeutic interventions by involving consumers and care givers. The system should also reflect the core values of an organization like reflective practice and openness to reduce restrictive interventions. Incorporating strategies to monitor, report and evaluate care delivery system can be used to build the knowledge base and strategies to reduce restrictive interventions. Development of physical environment that can promote the safety and comfort as well as minimizing any distress experienced by patients can also support the reduction of such intrusive interventions (health.vic.gov.au, 2018).

Conclusion:

Restrictive interventions are the use of restraining or restrictive measures to limit the mobility and freedom of movement of individuals, and are mostly used for individuals with mental health conditions at risk to injury to self or others. However, the use of physical restraints can have adverse psychological and mental health effects as well as a significant relation to physical injury due to the restraints. Moreover, such interventions also can be used as a method of coercion and control, instead of its possible beneficial use. Because of such concerns, the Mental Health Act 2014 and Providing Safe Environment for All frameworks provide guidelines and policies to reduce the usage of restrictive intervention for mental health patients. The policies dictate that restrictive interventions are to be used only as the last option, and only for the least possible amount of time. Respect to the individual rights and autonomy of the patients as well as their families or caregivers and respect to their wishes and experiences are also highlighted in the guidelines, and it supports their participation in the decisions related to their care. The framework and legal guidelines increases the responsibilities of the healthcare professionals, in the usage of least restrictive treatment strategies and ensure that any use of restraining intervention be properly and effectively reported with concerned individuals. The policies place patients at the centre of care, and foster the development of therapeutic relation and trust between the patients and healthcare professionals.

Importance of Providing a Safe Environment for All

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