RESTRAINT MINIMISATION IN MENTAL HEALTH &
Protocol
MENTAL HEALTH &
ADDICTION SERVICES
MHAS.A1.2
ADDICTION SERVICES
PROTOCOL
STANDARD
It is the Bay of Plenty District Health Board (BOPDHB) Mental Health & Addiction Services
(MH&AS) protocol intent that the use of restraint for patients / clients in all forms is minimised
and that when practiced, it occurs in a safe and respectful manner.
OBJECTIVE
To ensure that the MH&AS staff have knowledge of restraint, with regards to the
requirements of legislation, consumer rights, current standards and relevant professional
codes of conduct.
STANDARDS TO BE MET
1. Indications for Restraint
1.1 The following are situations where restraint MAY be indicated:
a) When an individual’s behaviour indicates that he / she is seriously at risk to self or
others.
b) When an individual makes a serious attempt or act of self-harm.
c) When an individual makes a sustained or serious attack on another person.
d) When an individual seriously compromises the safety of the environment, e.g. by
damage to property.
e) When it is necessary to give a planned prescribed essential treatment to an
individual who is resisting and is being treated compulsorily.
2. Situations of Extreme Caution
2.1 When the use of restraint would threaten or compromise the physical well-being of
the individual or others. Consideration must be given to the comparative risks of using
restraint or not.
3. Assessment
3.1 All clients will have an assessment carried out to include risk, triggers and early
warning signs and identification of de-escalation interventions / strategies to ensure
that restraint is used only where it is clinically indicated and justified.
3.2 Assessment information will form the basis of an individualised nursing care plan and
risk management treatment plan which will be formulated and documented in the
patient’s health record.
3.3 Assessments will be carried out by the allocated Registered Nurse (RN) and / or the
Responsible Clinician / On call doctor in consultation with the client and whanau /
family, if nominated by the client, and other members of the multidisciplinary (MDT)
team.
4. Legal / Ethical
4.1 The requirements of legislation, consumer rights, current standards and relevant
professional codes of practice will be met.
Issue Date:
Oct 2014
Page 1 of 5
NOTE: The electronic version of
Review Date:
Oct 2017
Version No: 4
this document is the most current.
Any printed copy cannot be
Protocol Steward: Associate Director
Authorised by: Business Leader &
assumed to be the current version.
of Nursing, MHAS
Clinical Director, MH&AS
RESTRAINT MINIMISATION IN MENTAL HEALTH &
Protocol
MENTAL HEALTH &
ADDICTION SERVICES
MHAS.A1.2
ADDICTION SERVICES
PROTOCOL
4.2 Practice will be guided by ethical principles including acting for the good of the client,
avoiding harm to the client, self and others and respecting the dignity of the client and
their human rights.
4.3 Requirements of the Mental Health Act 1992 and its amendments will be met.
5. Education / Training
5.1 Staff employed on the adult acute mental health units (full-time, part-time and
casual/on-call staff excluding administrative staff) and DAO’s / Crisis Service Staff are
required to undertake a 4 day training course in personal restraint : “Safe Practice &
Effective Communication” (SPEC) Adult
and will attend revalidation training for one
day at least twice within an 18 month period.
5.2 Staff employed at the Mental Health for Older Persons inpatient ward (excluding
administrative staff) are required to undertake a 2 day training course in personal
restraint: “Safe Practice & Effective Communication” (SPEC) Older Adult
and will
attend revalidation training for ½ day at least twice within an eighteen month period.
5.3 This training is carried out by approved Mental Health Service SPEC trainers and
Clinical Co-ordinator/Team leaders have the responsibility of ensuring that staff are
included in planned revalidation training days in a timely manner.
5.4 All training programmes will be approved by the Practice of Restraint Advisory Group
(PRAG), be evidenced based and consumer focused and shall include reference to
and detail related to:
a) Adequate and appropriate individual planning of care and/or support in order that
alternatives to restraint can be identified in conjunction with the client.
b) The requirements of the Health & Disability Services (Restraint Minimization and
Safe Practice) Standards, 2008.
c) Current accepted good practice.
d) Assessment, Risk assessment and management, de-escalation training.
e) Trauma Informed Care
f) Decision making skills required in relation to the use/non-use of restraint.
g) Technical skills related to the safe use of restraint techniques.
h) Demonstration of a wide range of de-escalation skills.
i) Participants demonstrating an ability to function effectively as a member of a team
in a potentially threatening situation.
j) Participants demonstrating knowledge in the process of debriefing.
k) Participants demonstrating knowledge regarding the Mental Health (Compulsory
Assessment and Treatment) Act 1992 and the legal implications of the
management of violent and aggressive clients.
5.5 Individualized records of the education and competency of MH&AS staff in relation to
SPEC training will be kept in a central mental health service staff training register.
5.6 All training will be carried out by appropriately trained staff. Appropriately trained staff
can be identified as having completed the Mental Health Service Train the Trainer
course and have a minimum of at least 3 years practice experience, some of which
has been within an acute inpatient mental health facility.
5.7 The SPEC training course will be reviewed and updated on an ongoing basis
(minimum 3 yearly).
Issue Date:
Oct 2014
Page 2 of 5
NOTE: The electronic version of
Review Date:
Oct 2017
Version No: 4
this document is the most current.
Any printed copy cannot be
Protocol Steward: Associate Director
Authorised by: Business Leader &
assumed to be the current version.
of Nursing, MHAS
Clinical Director, MH&AS
RESTRAINT MINIMISATION IN MENTAL HEALTH &
Protocol
MENTAL HEALTH &
ADDICTION SERVICES
MHAS.A1.2
ADDICTION SERVICES
PROTOCOL
6. Initiating / Ending Restraint
6.1 Restraint shall only be initiated when attempts at de-escalation have been found to be
inadequate to prevent the use of restraint or where a client’s behaviour immediately
threatens serious harm to themselves or others.
6.2 The decision to initiate or discontinue restraint will be made when:
a) The environment is appropriate and safe for successful initiation or
discontinuation.
b) When adequate resources are assembled to ensure it is safe to do so.
c) When appropriate planning and preparation has occurred.
6.3 Any decision to initiate restraint will be made by the RN allocated to that client on that
shift (may not always be possible if open ward scenario), in consultation with the Shift
Co-ordinator (may not always be possible if IPC scenario). Staff who initiate and
participate in restraint procedures must at all times be competent in personal
restraint.
6.4 Discontinuation of restraint will occur following on-going assessment and evaluation
of outcomes. The decision will be made by the Co-ordinator of the restraint, in
consultation with the restraint team and will be a planned process.
6.5 The Responsible Clinician / On-call doctor will be notified as soon as is practicable of
restraint and outcomes.
7. Communication / Support
7.1 Staff must maintain clear, effective and appropriate communication with each other,
ensuring they understand what is happening and that the procedure is carried out
safely.
7.2 Prior to and throughout restraint staff must maintain clear, effective and appropriate
communication with the client, ensuring they understand what is happening and that
their communication needs are met.
7.3 Wherever possible and practical the client and their whanau / family, as nominated,
will be consulted about the use or potential use of restraint.
7.4 Wherever possible clients may have access to whanau / family providing the safety of
the environment, individual and others will not be compromised.
8. Observation and Care
8.1 Physical well-being will be promoted throughout the procedure including ongoing
assessment of:
a) Airway
b) Breathing to avoid positional asphyxia.
c) Circulation
d) Level of Consciousness/vital signs
e) Circulation and range of motion extremities
f) Signs of injury/discomfort
8.2 Once confirmed, ongoing assessment of mental status, level of risk and response to
restraint can be carried out.
8.3 All clients requiring full restraint must be assessed by the duty psychiatrist as soon
as is practicable
Issue Date:
Oct 2014
Page 3 of 5
NOTE: The electronic version of
Review Date:
Oct 2017
Version No: 4
this document is the most current.
Any printed copy cannot be
Protocol Steward: Associate Director
Authorised by: Business Leader &
assumed to be the current version.
of Nursing, MHAS
Clinical Director, MH&AS
RESTRAINT MINIMISATION IN MENTAL HEALTH &
Protocol
MENTAL HEALTH &
ADDICTION SERVICES
MHAS.A1.2
ADDICTION SERVICES
PROTOCOL
9. Prolonged Restraint
9.1 If the individual requires restraint for a prolonged period of time (over 60 minutes)
safe removal to a suitable designated area may be appropriate using an approved
technique. This should be attempted as soon as it is safe to do so.
9.2 During the period of restraint the client may be offered fluid and nourishment, the
opportunity to attend to personal hygiene needs and toileting, suitable clothing,
medications, exercise and activity (active or passive) as appropriate.
10. Restraint Use during Transportation / Transfer
10.1 The transportation / transfer of consumers requiring to be restrained will only be
undertaken in an emergency / crisis.
10.2 The transfer of consumers between in-patient units requires the approval of the
person’s Responsible Clinician and / or DAMHS.
10.3 For individual’s requiring restraint for transportation / transfer.
a) The transfer team will identify a restraint leader.
b) If physical restraint is indicated, physical restraint should be applied in a
manner that enables the consumer to be seated with dignity, comfortably and
without undue distress in the transfer vehicle.
c) A Restraint kit bag including First Aid Kit will be carried by the transfer team
d) The transfer team will carry a means of communication (Mobile phone,
Blackberry, 2-way radio etc) during transport / transfer.
10.4
Please Note:
a) Procedures regarding the transfer of consumers between In-patient Psychiatric
Units are detailed in
Bay of Plenty District Health Board Mental Health &
Addiction Services protocol MHAS.B1.4 IPU Transfers
b) Procedures regarding the general requirements for the transportation of
consumers are detailed i
n Bay of Plenty District Health Board Mental Health &
Addiction Services protocol MHAS.A1.48 Transportation of Tangata
Whaiora/Consumers
11. Defusing
11.1 Appropriate support and defusing will be offered to the client, their nominated
whanau / family as soon as possible after the process as is safe and practical. It is
critical that the client and whanau have an opportunity to express their feelings and
to discuss events leading up to and during the restraint. And ideas for how the
client may be de-escalated and restraint avoided in future. Other witnesses, allied
staff or other clients should also have an opportunity to express their feelings and
to discuss events leading up to and during restraint.
11.2 All staff will be encouraged to defuse after all restraint situations and access to
appropriate support will be provided as per BOPDHB policy 3.50.02 protocol 7
Supporting Staff. The personal restraint leader for any given incident will be
responsible for facilitating a defusing session for involved staff.
12. Documentation
12.1 The following documentation will be completed after all restraint procedures:
a) Electronic Reportable Event form
b) Electronic Restraint Use form
c) Seclusion Incident Recording form (if relevant)
Issue Date:
Oct 2014
Page 4 of 5
NOTE: The electronic version of
Review Date:
Oct 2017
Version No: 4
this document is the most current.
Any printed copy cannot be
Protocol Steward: Associate Director
Authorised by: Business Leader &
assumed to be the current version.
of Nursing, MHAS
Clinical Director, MH&AS
RESTRAINT MINIMISATION IN MENTAL HEALTH &
Protocol
MENTAL HEALTH &
ADDICTION SERVICES
MHAS.A1.2
ADDICTION SERVICES
PROTOCOL
d) A detailed entry in the clinical file
e) Risk Review Updated (if relevant)
f)
A thorough update in the clients treatment plan
12.2 Copies of all forms will go to the Team Leader of the staff member(s) undertaking
the restraint.
12.3 A summary of personal restraint incidents will be formulated by the MH&AS Quality
& Patient Safety Coordinator on a monthly basis.
13. Evaluation and Review
13.1 Evaluation shall determine if the intended outcome was achieved or not for each
individual client and consideration shall include the decision to continue or end the
restraint.
13.2 Evaluation of restraint shall occur to validate the appropriateness of restraint,
ensure safety and identify alternative interventions including the ending of restraint.
Wherever possible this shall occur in partnership with the client, and whomsoever
the client wishes to have present.
13.3 The frequency and content of on-going education in relation to restraint
minimization and safe practice shall be determined by the findings / outcomes of
the Quality Improvement Group and the Personal Restraint Advisory Group.
REFERENCES
Mental Health (Compulsory Assessment & Treatment) Act 1992 & Amendments
NZS 8134.2:2008 Restraint Minimization and Safe Practice Standards
Safe Practice & Effective Communication (SPEC) Adult: Participant Manual
Safe Practice & Effective Communication (SPEC) Adult: Trainers Manual
Safe Practice & Effective Communication (SPEC) OLDER: Participant Manual
ASSOCIATED DOCUMENTS
Bay of Plenty District Health Board policy 1.2.4 Restraint Minimisation & Safe Practice
Bay of Plenty District Health Board policy 1.1.1 Informed Consent
Bay of Plenty District Health Board policy 5.3.1 P6 OSH Accident Claims & Return to
Work
Bay of Plenty District Health Board Mental Health & Addiction Services protocol
MHAS.A1.48 Transportation of Tangata Whaiora/Consumers
Bay of Plenty District Health Board Mental Health & Addiction Services protocol
MHAS.B1.4 IPU Transfers
Bay of Plenty District Health Board Multidisciplinary Admission to Discharge Planner
Form (7760)
Seclusion Event Form
Treatment Plan Acute In-Patient Units
Issue Date:
Oct 2014
Page 5 of 5
NOTE: The electronic version of
Review Date:
Oct 2017
Version No: 4
this document is the most current.
Any printed copy cannot be
Protocol Steward: Associate Director
Authorised by: Business Leader &
assumed to be the current version.
of Nursing, MHAS
Clinical Director, MH&AS
