RESTRAINT MINIMISATION & SAFE PRACTICE -
Policy 1.2.4
STANDARDS
Protocol 0
RESTRAINT PROTOCOL
STANDARD
To ensure that the use of restraint for patients / clients at Bay of Plenty District Health Board
(BOPDHB) in all forms is minimised, and that when practiced, it occurs in a safe and
respectful manner.
STANDARDS TO BE MET 1. Organisational Responsibilities
1.1. BOPDHB staff practice competent, safe care in relation to restraint minimisation,
always considering the least restrictive interventions, and appreciating the
physical and psychological impact restraint has on the individual consumer, their
family / whānau and others.
1.2. BOPDHB provides training to all staff as appropriate and ensures competency
levels are maintained.
1.3. All staff will be encouraged to debrief after all restraint situations and access to
appropriate support will be provided.
1.4. The principles of Restraint Minimisation and Safe Practice (RMSP 8134.2 2008)
are applied to seclusion usage, and a regular review occurs in order to consider
the appropriateness of the technique, ensure safety, and identify alternative
interventions (refer BOPDHB Mental Health & Addiction Services protocol
MHAS.A1.45).
1.5. Restraint usage is reviewed at regular intervals in order to validate the
appropriateness of techniques, ensure safety and identify alternative interventions.
1.6. Any new forms of restraint will be approved by the Clinical Governance Committee
as per policy 1.2.4 protocol 1 Restraint Minimisation & Safe Practice - Approval of
Practices
1.7. A Restraint Minimisation Co-ordinator will be appointed and be responsible for
monitoring compliance to safe standards of practice by:
Facilitating restraint minimisation education within BOPDHB
Maintaining an auditable Restraint Register and generating reports as required
Co-ordinating the functions of the Practice Restraint Advisory Group (PRAG).
2. PRAG Responsibilities
2.1 The PRAG will meet regularly, no less than quarterly, to review and evaluate restraint
minimisation processes at the service level and report findings to the Performance &
Environment Committee.
2.2 Monitor trends and provide a report to the Performance & Environment
Committee if there are notable changes in trends or as required in the event of a
major issue or adverse event associated with restraint practice.
2.3 On an annual basis review all forms of restraint practices, to evaluate and identify
education programmes.
2.4 Endorsement of new restraint minimisation practices.
2.5 Ensure that the auditable record of restraint use meets the requirements of the
Restraint Minimisation Standard and Mental Health (CAT) Amendment Act 1999,
section 12b “Use of Force” that all instances of restraint are documented and
maintained in the auditable register.
Issue Date:
May 2017
Page 1 of 2
NOTE: The electronic version of
Review Date: May 2020
Version No: 4
this document is the most current.
Any printed copy cannot be
Protocol Steward: Restraint
Authorised by: Director of Nursing
assumed to be the current version.
Co-ordinator
RESTRAINT MINIMISATION & SAFE PRACTICE -
Policy 1.2.4
STANDARDS
Protocol 0
RESTRAINT PROTOCOL
3. Clinical Staff Responsibilities
Consideration of the following in the use of restraint minimisation (actual or potential):
3.1 All staff must read and be familiar with the BOPDHB policy 1.1.1 Informed Consent.
3.2 The requirements of legislation, consumer rights, current standards and relevant
professional codes of practice are met throughout the use of restraint minimisation
3.3 The patient / client’s dignity, privacy and self-respect during restraint are promoted.
3.4 The patient / client, and where indicated, their family / whānau or significant others
are empowered to participate in all decisions relating to restraint minimisation
through the facilitation of active support / advocacy (refer to BOPDHB policy 1.1.1
Informed Consent.
3.5 A comprehensive assessment that recognises the needs and risks for the patient /
client, and identifies proactive de-escalation interventions or strategies that ensures
restraints are only used where it is clinically indicated and justified.
3.6 The physical and psychological safety of patients / clients is maintained throughout
the restraint minimisation process through professional, timely and appropriate
monitoring (including observation).
3.7 A timely, transparent system of evaluation and review of restraint minimisation for
each patient / client occurs in order to promote safety and identify opportunities to
reduce or end the restraint interventions.
3.8 The specific cultural needs of consumers during each stage of de-escalation and
restraint minimisation are recognised. Relevant cultural advice and / or guidance
should be sought in order to maintain and practice cultural safety, through the use
of best practice cultural models (refer BOPDHB policy 1.4.4 Maori Cultural Safety).
3.9 Appropriate support and debriefing is offered to the patient / client, nominated
whānau / family, health professionals and other staff involved with the restraint
episode as soon after the process as is safe and practical.
ASSOCIATED DOCUMENTS
Bay of Plenty District Health Board Restraint Minimisation & Safe Practice controlled
documents
Bay of Plenty District Health Board policy 0.0 Glossary of Terms / Definitions
Bay of Plenty District Health Board policy 1.1.1 Informed Consent
Bay of Plenty District Health Board policy 2.1.1 Risk Management
Bay of Plenty District Health Board policy 2.1.2 protocol 2 Controlled Document
Development Standards
Bay of Plenty District Health Board policy 2.1.2 protocol 6 Controlled Document Review
Standards
Bay of Plenty District Health Board policy 2.1.3 Hazard Management
Bay of Plenty District Health Board policy 2.1.4 Incident Management
Bay of Plenty District Health Board policy 5.4.7 Threatening Behaviour, Bullying,
Harassment and Violence in the Workplace - Management
Bay of Plenty District Health Board policy 7.104.1 protocol 3 Care Delivery – Observing
Patients
Bay of Plenty District Health Board Practice of Restraint Advisory Group (PRAG) Terms
of Reference
Bay of Plenty District Health Board Incident Management Form
Issue Date:
May 2017
Page 2 of 2
NOTE: The electronic version of
Review Date: May 2020
Version No: 4
this document is the most current.
Any printed copy cannot be
Protocol Steward: Restraint
Authorised by: Director of Nursing
assumed to be the current version.
Co-ordinator
