20% of the overall mark for CHCICS404A
pass level
- names and defines all three
- gives at least two relevant examples not directly from the practice guide
- lists 2 key points for both the act and charter
- each scenario has restrictive intervention correctly identified, at least two barriers and at least 2 alternatives
1. The Disability Act refers to three types of restrictive interventions that must be reported to the Senior practitioner. name and define these three types of restrictive practices.
Seclusion is defined as locking a person with a disability in a room or other location, solely, at any time of day or night. This can be in any area or any room of any place such as in their bedroom or the garden. For people who are unable to operate door handles, the door may be simply closed, effectively ensuring the person cannot leave the room. For a person who depends on a wheelchair for mobility it could be leaving them in their chair in a way that they cannot operate it themselves, such as taking away the control pad or leaving the brakes on.
Mechanical Restraint is defined as the use of any device to prevent restrict or subdue movement of a persons body for the primary purpose of behavioural control, but excluding the use of an authorised mechanical restraint recommended by a medical practitioner or therapist for use at identified times and places for therapeutic purposes (i.e. to explicitly to enhance health and well being) and an authorised mechanical restraint recommended by a medical practitioner or therapist to support a person to participate in certain identified activities of daily living such as at meal times, or to enable a person to be transported safely according to law such as a seat belt buckle guard.
Chemical restraint is defined as any medication that is used to subdue a person or control their behaviour. This does not include appropriate medical treatment for physical or mental illnesses or condition, where the prescription is primarily for the treatment of the illness, or the medication is used to enable a treatment, such as at the dentist. Chemical restraint includes the prescription of psychotropic medications for a medically diagnosed mental illness where the dosage is high, or where a number of medications are taken together increasing the individual side effects and causing toxicity.
2. The legislation refers to "other restrictive interventions" which have been further described by the Office of the senior Practitioner. Give some examples of other restrictive practices you have seen or heard being used.
The most common "other restrictive practice" that I have witnessed is that residents are not allowed to go into the office part of the house or into the filing cabinet where all their books and medications are kept. The filing cabinet is kept locked or there are signs on the door that states residents are not allowed to go in there. This is an environmental restraint.
One resident that I have supported is not allowed to go anywhere by herself. The reason given is her epilepsy is too severe and she needs 24hr a day supervision. She sometimes will walk down to the shops or her local primary school where she works in the library, but those occasions are very infrequent. This resident is not allowed to go to the movies by herself, or go on a train or bus. She requires an attendant carer to go places with her, she is provided with 12 hours a week of one-on-one time, the resident must pay mileage in the attendant carers vehicle at the rate of sixty cents per kilometre. Consequently this person does not go very far from home and never goes to the movies. This is an environmental restraint.
Another resident I have supported is made to stay in his chair. This person is blind and he has an acquired brain injury. He has a recliner chair in the communal part of the house. He is expected to sit in the chair unless he has been taken to the garage to smoke a cigarette, or he is going to the toilet, or he is spending one-on-one time with an attendant carer. If he leaves his chair, the house staff say "Where are you going? Sit back in your chair, you can't go walking around the house" the reasons that they give are logical but they are definitely using an "other restrictive practice". The reasons are; he has a balance problem and will usually fall over and hurt himself (even though he has a walking frame), and that he is blind so he doesn't know where he is going anyway, and he will crash into the people who are in the wheelchairs. This is Psycho-social restraint.
The same resident as above will repeatedly ask for cups of tea, cigarettes and if he can use the toilet. This person doesn't remember how long it has been since his last cup of tea or cigarette, and he is incredibly bored, he also has significantly perseverative behaviours. He will ask over and over again. The response from staff will often be annoyed frustrated and short tempered replies like "stop nagging, you just had a cup of tea", and "the more you nag the longer you will have to wait", and "you are driving me mad, you just go on and on, please just sit there and don't say a word", the person usually replies with "sorry M'aam, I will not nag". This form of "other restraint" uses consequence driven strategies that do not address the reason for the persons behaviour.
3. According to the disability Act, restrictive interventions can only be used when..... the disability service provider is approved to use restrictive interventions, and the use of seclusion or restraint is included in a behaviour management plan, and a person who is independent of the disability service provider has explained the use of restraint or seclusion to the person with the disability and that the person has the right to seek a review of the decision by VCAT, and the behaviour management plan has been given to the Senior Practitioner.
4. According to the Victorian Charter of Human Rights and Responsibilities, any limit or restriction on a persons rights can only be justified when...... it is specifically authorised by law. This means that a person's freedom of movement is restricted for the purpose of behaviour control to prevent the person from causing physical harm to themselves or others. The restrictive intervention must be approved in the persons treatment/behaviour support plan. The disability service provider must ensure that any other resident affected by the intervention must have strategies in place to minimise the impact of this restriction on them.
5. For each of the following scenarios identify:
a. The restrictive Practice being used.
b. The factors that may be being used to rationalise the use of restrictive practices.
c. Alternative solutions to the restrictive practice.
i. A day program locks the kitchen and the cupboards in the kitchen as they are concerned about what might happen if one person accesses the knives. There is also another person with Prader Willi syndrome at the centre who staff need to supervise with regards to food. Access to food and drinks is only obtained by staff using their keys to unlock the kitchen.
a) Other restrictive practice - Environmental restraints, lack of free access to all parts of a persons environment, also the consequence-driven strategies that do not address the reason why the people are behaving in an undesirable way in the kitchen. The reactive strategy in this case is to lock the kitchen. Free access to food and drink is a basic human right.
b) This rule would have been set in place to reduce the likelihood of physical harm, because one person has previously used knives in an unsafe manner. Another person with has Prader-Willi syndrome has challenges with obesity and heath related problems, her doctor has recommended that her food intake is reduced, this is being monitored by staff. When someone has Prader-Willi syndrome they are very likely to eat unhealthy frozen, uncooked food and food scraps from the rubbish bin, this is a significant risk to their personal health.
c) Education would be the key element in this situation. Educate the residents to handle knives correctly and safely. An education program based on healthy eating and physical education would benefit all the residents of the house as well as the person with Prader Willi syndrome. Install a smaller fridge with a range of healthy foods for free access by everyone. Mindfulness training can help people with Prader-Willi syndrome to successfully limit their intake of food) Staff need training in alternative and augmentative communication to maximise the opportunities for the residents to make choices and participate in their daily routine. Review Health and safety operations that affect residents everyday connection and engagement with staff so that they are more equally balanced and empowering rather than the usual powerless and controlled relationships.
ii. Penny is 35 and has Autism and she loves to walk. She does not like being in confined spaces for long and if there are too many people around she likes to leave and go for a walk. Sometimes she does not return for several hours. Because of their "duty of Care" staff at both her group home and her day service have started locking all the doors at all times so she is unable to leave the premises. They have now noticed an increase in self injurious behaviour.
a) Penny could be subject to Seclusion if she is solely locked in an area or room but it is more likely that Penny is being subjected to Environmental Restraints where she is being restricted from free access to all parts of her environment. Locking Penny inside her home is a form of restriction on her human right of freedom of movement.
b) Penny would be restricted from accessing her environment because the disability service provider believes that they are preventing her from coming to physical harm. The disability service provider is likely to believe that they are stopping Penny from being hurt on the road, or becoming a victim of crime, or committing a crime herself, they believe that Penny could become lost and not be able to find her way home, causing her distress. The disability service provider does not know of any instances where Penny has been unsafe or distressed. Duty of care motivates the staff to lock the doors because they want to keep Penny safe, the restriction is causing Penny to increase self injurious behaviour.
c) Penny's skills to independently access the community should be evaluated. Skills such as road safety awareness, and using communication aids should be developed and enabled. Using a weekly planner, plan with Penny the days and times she will go for a walk. Choosing preferred activities such as enjoyable work and fun things to do at home should be promoted. Use shadow support to follow Penny when she chooses to go for a walk to observe her behaviour. Penny could also move to a smaller quieter day service and group home where she feels comfortable to stay at home more often.
iii. Ben is 25 and has a history of aggressive behaviours, including physical assault of staff. Many staff are anxious about supporting Ben and despite his behaviour support plan there is inconsistency in how he is approached when he is becoming aggressive. Some staff send him to his room and tell him he cant come out until he behaves himself. Some staff tell him if he threatens them they will not take to the gym (his favourite place to go). Other administer sedative medication at the first sign of concern.
a) Chemical restraint - sedative medications are administered at the first sign of concern to prevent Ben's aggressive behaviours from appearing. Ben is also subject to other restraints; environmental, because he is being restricted from going to the gym as staff will not support him to go there, and psycho-social restraint is used when he is told he cannot come out of his room until he behaves himself. These restraints affect Ben’s human rights. Such as Ben's freedom of movement which is a basic human right, Ben’s right to dignity is being limited because he is not consenting to the chemical restraint, he has the right refuse medical treatment unless he is subject to a compulsory treatment order, he also has the right to be protected from cruel treatment.
b) Rationale of the approaches used by the disability service provider include; physical assault and potential injury of staff, his history of doing it before, the potential to do it again, removing his freedom to go to the gym impacts Ben in a way that keeps his behaviour in check (it works), sending Ben to his room removes him from the environment and staff feel less anxious, telling Ben to spend time in his room and not come out until he behaves himself gives everyone time to cool down and relax, making Ben stay in his room and cool off stops Ben from hurting people, giving Ben sedation at the first sign of concern stops his behaviour from advancing to another stage, and therefore stops people getting hurt.
c) Ben’s behaviour support plan needs to be re-assessed, right from the beginning. Starting with data collection, a functional behaviour assessment, Doctors and Specialists evaluations regards the PRN medication and check-ups, a new behaviour support plan needs to be developed including Pro-active strategies. Ben’s needs intervention and positive behaviour support to reduce the incidence of behaviours and enhance the quality of his life. Staff need to collaborate on the best response and agree to be consistent in their approaches, feedback and discussion are required so that the plan can be reviewed and evaluated. This way Ben gets the best support that he possibly can. Pro-active strategies should be employed so that Ben’s behaviour does not escalate to “the first sign of concern” and beyond, where reactive strategies have usually been required. Examples of pro-active strategies are, develop and augment Ben’s communication skills so that he can express his needs, take Ben to the gym as often as he would like to go, take Ben to a boxing class so he has an appropriate outlet for hitting things, change Bens environment and consider moving him or another resident to a group more suited to his personality, teach Ben anger management strategies, develop connections within the local community and encourage opportunities for Ben to safely take part in public life.
iv. Andrew is a young man with a severe intellectual disability. he often removes his clothing while in public. because this is embarrassing and limits the opportunity for him to go into the community, his disability support workers place him in overalls that are under his everyday clothing so that he is unable to unfasten the buckles and he cannot take all his clothes off.
a) Andrew is subject to mechanical restraint because he is dressed in clothing that he cannot remove. Mechanical restraint is the most restrictive form of intervention. The reason that Andrew cannot remove his clothing is not significant, the fact that he wants to but is restrained from doing so implies that his support staff are failing to fulfill their duty to protect Andrews human rights, in the areas of Human Dignity, Freedom and Equality.
b) Staff are embarrassed when they have Andrew out in the community and he is removing his clothing so they force him to stay dressed by putting clothes on him that he cannot remove or they only take him places where it might not matter so much if he takes off his clothing and therefore limit his opportunities. Andrew could be charged with indecent exposure if he is found to be naked in public so putting Andrew in overalls protects him from criminal prosecution and protects the public from his behaviour. Andrew could become sick or injured by being in public without clothing and exposed to the elements, such as sunburn, frostbite, colds, cuts and grazes, our skin alone is not suitable personal protection.
c) Any less restrictive means to achieve the purpose of keeping clothing on Andrew and respecting his human rights is preferable to the current method. The first steps would be to ensure that Andrew has a multi-element behaviour support plan. The Senior Practitioner must approve restrictive practices and this will be reflected in Andrews Behaviour Support Plan. Possibly Andrew needs a separate Behaviour Support Plan for the times that he is in the community. Andrew should have medical check-ups to rule out any illness as the reason for his behaviour. Staff should address any personal needs like hunger and tiredness before trips into the community are attempted. Alternative strategies to Mechanical restraint are, one-on-one support while in the community. A more reasonable and justifiable and less restrictive intervention could be to use medication that could be reduced over time while using positive behaviour support to teach Andrew coping skills to use whilst on outings. Additionally I recommend to assess Andrews communication level using the Triple C and develop appropriate communication aids such as a communication dictionary and a book about me, use chat books and social stories to reinforce positive behaviour, and teaching Andrew replacement skills such as using community request cards, and making choices.
For this assessment I have accessed information in these places;
Office of the Senior Practitioner Publication - Enlivening human dignity and rights – The Senior Practitioner implementing the Victorian Charter of Human Rights and Responsibilities 2006 - Guidelines for service providers and practitioners (July 2009)
Office of the Senior Practitioner Publication - Practice Guide - Other restrictive interventions: locked doors, cupboards, other restrictions to liberty and practical ideas to move away from these practices (January 2010)
Office of the Senior Practitioner Publication - Physical restraint in disability services: Current practices, contemporary concerns, and future directions (March 2009)
Internet research at VALID (http://www.valid.org.au/)
3029 words
3029 words
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