In reality, restrictive practices are linked to a variety of adverse care outcomes. For example, mechanical restraint - when used to prevent falls - may actually increase the risk of falls, as it can cause muscle deterioration if used for a prolonged period of time (SA DoH 2015).
Furthermore, there is evidence that restrictive practices are ineffective in preventing falls, and may actually worsen changed behaviours (VIC DoH 2018).
It is clear that more appropriate approaches are needed.
In order to reduce the need for restrictive practices, there are a variety of alternative strategies that can be used to de-escalate situations, or even prevent changed behaviours or falls from occurring in the first place.
Barriers to Preventing Restrictive Practices
Firstly, let’s explore some of the reasons why aged care staff may have difficulty minimising the use of restrictive practices.
The Royal Commission into Aged Care Quality and Safety (2019) identified several potential barriers, including:
Fear of resident injury
Staff and resource limitations
Inadequate staff knowledge about the implications of restrictive practices
Inadequate staff knowledge about alternatives to restrictive practices
The beliefs and expectations of staff, family and residents
Paternalistic views towards older adults
Complex resident care needs
Inadequate collaboration between healthcare professionals and aged care staff.
Alternative Strategies to Restrictive Practice
Much of preventing the need for restrictive practices hinges upon providing empathetic care and ensuring the comfort and safety of residents (VIC DoH 2018).
In general, aged care services should:
Recognise behavioural changes when they occur and identify residents who may be at risk of requiring restraint
Conduct a comprehensive assessment of each resident and develop an individualised plan if any risk factors are identified. The assessment should include:
The resident’s routines, preferences and values
Refer the resident to other services (e.g. general practitioner, physiotherapist) if deemed necessary
Assess behaviour interventions and falls prevention strategies on an ongoing basis
Involve the resident and their family in the process of developing and implementing strategies
Ensure staff are adequately trained in the ethics of restraint and possible alternatives
Recognise situations that may cause residents to become distressed, anxious or aggressive.
(VIC DoH 2018)
To help reduce the risk of falls without resorting to restrictive practices, you can:
Use equipment such as non-slip mats and hip protectors
Ensure the service environment is secure, well-lit and safe for wandering
Address underlying health issues such as mental health conditions, sensory loss, poor balance or unstable blood pressure, and ensure medication is reviewed regularly
Ensure the resident’s bed height is appropriate for their needs and the brakes are applied
Keep mobility aids close by
Ensure seating meets the resident’s needs
Implement an alarm system to notify staff of potential dangers such as wandering
Ensure indoor areas are free of clutter
Reduce glare in corridor areas
Use non-slip or carpet flooring
Implement signage and visual aids to aid orientation
Ensure outdoor areas are safe and protected
Provide sensory aids, if required.
(My Aged Care 2016; VIC DoH 2018)
Managing Changed Behaviours
Note: Changed behaviours are sometimes referred to as ‘behaviours of concern’ or ‘challenging behaviours'. However, the term 'changed behaviours' is preferred as it avoids negatively stigmatising people who display behaviours that indicate a need for support (DSA 2021).
Providing a Respectful and Welcoming Service Environment
While reducing the need for restrictive practices partially involves exploring alternate options during challenging situations and learning how to effectively de-escalate conflict, prevention should begin at a grassroots level. In other words, you should consciously ensure your interactions, communication and engagement with residents actively address their needs and make them feel comfortable. This, in turn, will aim to reduce the incidence of changed behaviours in the first place (SA DoH 2015).
The following are some practical suggestions for caring for residents in a way that will help reduce changed behaviours:
Ensure you deliver trauma-informed care that takes into account the resident’s past traumatic experiences. Make sure they feel welcome and provide them with options so that they do not feel trapped
Engage with the resident and develop a therapeutic relationship with them
Always deliver person-centred care
Be polite and respectful, and practice effective and empathetic communication
Meet the resident’s immediate needs
Provide the resident with access to a range of meaningful activities they can choose from
Align the resident’s routine with what they are used to (e.g. shower and sleeping patterns)
Respect the resident’s communication needs
Avoid invading the resident’s personal space
Inform the resident in advance before performing an action
Consider the resident’s values and preferences
Give the resident capacity to make choices or suggest alternatives
Surround the resident with familiar objects from home
Encourage visitors and staff–resident interaction
Ensure continuity of staff, if possible
Offer relaxing activities (e.g. therapeutic touch or massage)
Decrease sensory overload
Individualise the resident’s routine.
(SA DoH 2015; VIC DoH 2018)
Responding to Changed Behaviours
Note: For specific guidance on responding to behavioural and psychological symptoms of dementia and using the ABC Approach to Behaviour Management, see Behaviour Management and BPSD.
It’s important to remember that changed behaviours generally have underlying causes. These may include:
Pain, discomfort or illness
Interruption to routine
Medication changes, side effects or interactions
Changes to the living environment
Wanting to communicate something
Boredom or loneliness
Hunger or low blood sugar
Mental illness (e.g. depression or anxiety)
Hallucinations or delusions
Drug, alcohol or smoking withdrawal
(Carer Gateway 2021; VIC DoH 2019)
When faced with changed behaviours, consider why this behaviour is occurring and how the resident’s unmet needs can be addressed.
Knowing the resident’s typical behaviour will help you to recognise changes (VIC DoH 2019).
It may be useful to keep a log of changed behaviours in order to identify a specific pattern or trigger. If a trigger is identified, try to avoid or reduce the resident’s exposure to this particular situation (Aged Care Guide 2019).
Any strategies that have previously been successful in managing this behaviour should also be recorded (VIC DoH 2019).
If the changed behaviours are having minimal impact on safety, wellbeing and quality of life, consider individualised, meaningful interventions such as:
Life review and life story work
Modifying the resident’s physical environment
Social inclusion such as one-to-one interaction or meaningful hobbies
If changed behaviours escalate, it is important to assess the risk this behaviour poses to the resident, yourself and others. Consider:
The type, degree and immediacy of risk
The nature, frequency and severity of the resident’s behaviour, and the context in which this behaviour is occurring
The severity of distress being experienced by the resident, as well as other people.
(VIC DoH 2019)
If the resident becomes agitated or aggressive, the following de-escalation strategies may help to calm the resident down and prevent the situation from intensifying further:
Speak to the resident in a quiet area with minimal stimulation, but ensure the safety of yourself and others. If there are safety concerns, respectfully and carefully divert the resident, or divert others from the area
Remove any items in the environment that are potentially dangerous
Call for extra assistance if needed
Observe the resident’s body language and try to understand what they may be feeling
Approach the resident calmly, empathetically and respectfully
When speaking to the resident, remain calm, introduce yourself, use their preferred name and provide verbal reassurance, e.g. ‘You are in a safe place and we are here to help’
Use non-threatening behaviour and body language
Ask the resident what the problem is. Ensure you allow adequate time for them to respond, and listen to their concerns
Validate the resident’s concerns and acknowledge their feelings (e.g. ‘I can see you’re upset’)
Avoid arguing or trying to reason with the resident
Apologise if the resident is upset about something that has happened (if reasonable)
Assess whether environmental stressors such as noise, temperature or light might be contributing to the behaviour, and remove or alter the environment if possible
Consider the following:
Does the resident need more information or an explanation?
If you are asking the resident to do something, can this be done later?
Is the resident able to make connections between their actions and the consequences?
The resident is allowed to feel angry - is it possible for them to vent in private?
Address any unmet needs
Redirect the resident to a meaningful activity that they enjoy
If it is safe to do so, leave the resident and return later.
(SA DoH 2015; VIC DoH 2018; DSA 2021)
If the situation continues to escalate and there is a risk of harm to the resident, yourself or other people, you may need to consider a restrictive practice. However, keep in mind that this should only ever be a last resort.