Review of Seclusion, Restraint and Observation of Consumers with a Mental Illness in NSW Health Facilities

CPSA welcomes the opportunity to provide comment on the review of seclusion, restraint and observation of consumers with a mental illness in NSW Health facilities. While CPSA acknowledges that residential aged care facilities are not regulated by the NSW Government, there is an urgent and pressing need to consider the use of restrictive practices, including restraint and seclusion, in this setting. The 68,000 plus NSW residents living in permanent residential aged care, many of whom have a mental illness, deserve high quality care delivered in the least restrictive environment possible[1].

As at 30 June 2016, 57% of people living in permanent residential aged care had a diagnosed mental health or behavioural condition and 52% had a diagnosis of dementia[2]. Research conducted by Alzheimer’s Australia estimates that the prevalence of physical restraint use in residential aged care ranges from 12%-49%3. Alzheimer’s Australia estimates up to 80% of people with dementia living in residential aged care have been prescribed psychotropic medications, which are a form of chemical restraint. The study notes that these medications are likely to have been inappropriately prescribed in some cases. CPSA also notes that a recent study highlighted that the use of physical restraint is sometimes associated with the deaths of aged care residents[4].

Staffing issues are rife in the residential aged care sector. Despite the increasing acuity and care needs of residents, the number of Registered Nurses (RNs) working in the sector has declined significantly from 21% of the direct care workforce in 2003 to just 14% in 2016. The majority of these RNs report spending less than one third of their time caring for residents. The declining role of RNs raises major concerns in light of the high prevalence restraint use in residential aged care. CPSA is very concerned that restraints are being administered without the appropriate clinical oversight of an RN. CPSA also notes that there is anecdotal evidence from residents, relatives and workers to suggest that restraints are being used to manage residents with behavioural issues when staff are too busy to manage those behaviours in a non-restrictive manner, rather than as a last resort.

The use of restraints and seclusion in residential aged care facilities is largely unregulated both at a state and national level. Neither the 1997 Aged Care Act, nor the 2014 Quality of Care Principles, which provide the basis of the aged care accreditation standards, provide guidance on the use of restraints. A study conducted by the Office of the Public Advocate in Queensland found the use of restrictive practices in residential aged care settings to be almost entirely unlegislated and unregulated and called for intervention in order to protect the human rights of older Australians[5].

CPSA notes that the Australian Department of Health has stated that there are toolkits covering the use of restrictive practices available to aged care staff and managers[6]. However, these toolkits have not been made public, so it is impossible to know whether they are consistent with clinical best practice. Accordingly, CPSA urges the NSW Government to push for the development of a national set of guidelines for the use of restrictive practices in residential aged care lead by clinical experts. Given that the improper use of restrictive practices amounts to a serious breach of individual rights, compliance with these guidelines must be mandatory and should be included in the accreditation standards.

That the NSW Government advocates for the introduction of national guidelines for the use of restrictive practices in residential aged care, which must be developed by clinical experts.

Given that the inappropriate use of restraints constitutes a major breach of a person’s human rights and places residents at risk, their ongoing use warrants immediate intervention in order to minimise the use of restrictive practices to situations where they are deemed necessary. Accordingly, CPSA urges the NSW Government to regulate the use of restrictive practices in NSW residential aged care facilities as a matter of urgency, until the Australian Government introduces a national regulatory framework.

That the NSW Government regulate the use of restrictive practices in NSW residential aged care facilities until the Australian Government introduces a national regulatory framework.

1. Australian Institute of Health and Welfare (2017) Explore services and places in aged care. Available: https://www.gen-agedcaredata.gov.au/Topics/Services-and-places-in-aged-care/Explore-services-and-places-inaged-care [Accessed: 19 September 2017]
2. Australian Institute of Health and Welfare (2017) People’s care needs in aged care. Available: https://www.genagedcaredata.gov.au/Topics/Care-needs-in-aged-care [Accessed: 19 September 2017]
3. Peisah, C. Skladzien, E. (2014) The use of restraints and psychotropic medications in people with dementia. Alzheimer’s Australia, paper 38 available: https://www.fightdementia.org.au/files/NATIONAL/documents/AlzheimersAustralia-Numbered-Publication-38.pdf
4. Bellenger, E., Ibrahim, J., Lovell, J., Bugeja, L. (2017). The nature and extent of physical restraint-related deaths in Nursing Homes: A systematic review. Journal of Aging and Health. DOI: 10.1177/0898264317704541
5. Office of the Public Advocate (Qld), Legal frameworks for the use of restrictive practices in residential aged care: An Australian and international comparative analysis (2017) available: http://www.justice.qld.gov.au/__data/assets/pdf_file/0005/524426/restrictive-practices-in-aged-care-final.pdf
6. Australian Government Department of Health (2017) Submission to Australian Law Reform Commission – Elder Abuse Issues Paper (41) available: https://www.alrc.gov.au/sites/default/files/subs/113._department_of_health_submission.pdf