In July 2023 we asked for your help to better understand how ‘restrictive practices’ were understood and interpreted in therapeutic residential care (TRC) across Australia. Through a blog on our website  CETC – How are restrictive practices interpreted in therapeutic residential care?, professionals who work within or alongside residential care shared their current understandings, questions and need for clarity about what constitutes restrictive practice in therapeutic residential care in Australia.

These are the results.

What you told us about restrictive practice

Overwhelmingly the survey results identified a lack of clear frameworks for making decisions about what constitutes restrictive practice in TRC. This confusion is experienced across systems and disciplines who are working together with young people in residential care.  The survey results indicated that 100% of respondents ‘agree’ or ‘strongly agree’ that there was misinterpretation between external agencies about restrictive practices. 85% of survey respondents indicated they ‘agree’ or ‘strongly agree’ that there is misinterpretation internal to their organisation about restrictive practices.

Over half of the respondents stated their agencies do not have relevant policy or procedures with supportive training to guide their decision making or direct practice in this area, as outlined in the graph below.

There are very clear and regulated restrictive guidelines for disability services focusing on seclusion, chemical, mechanical, physical, and environmental restraint, which are relevant for young people living with disability in TRC. Our survey respondents felt there are many gaps in applying these practices within TRC.

Survey responses raised the following observations about restrictive practices

Survey respondents shared their views in more detail about the use and frameworks to support their assessment, decision making, and practice in this area:

• There needs to be national consistency and alignment across agencies but also within national frameworks in Australia for restrictive practices.
• Agencies provide basic training about restrictive practices, but it contains few real-world, modern-day examples. More support is needed in this nuanced space to understand and balance dignity of risk and duty of care to support growth and development.
• The importance of balancing the principles of therapeutic care – what is best or safe for the child can sometimes be deemed a restrictive practice. There must be clarity about what can and cannot be done.
• Practice guide and definition improvements are also needed for kinship and foster carers, as well as caseworkers.
• Residential carers report that many are not confident that their decisions about behaviour management (in the moment) can or will be supported by their management. This can result in ensuring safety by prematurely resorting to using emergency services for behaviour management or emergency assessments. This last resort indicates significant anxiety in the care system at all levels.
• Many carers and supervisors/managers will simply ‘give in’ to the child’s demands to ‘keep the peace’ and avoid potential aggression.
• Currently the term “restrictive practice” appears to be interpretable to apply to more than just rights to basic needs such as freedom of movement. Respondents gave potential examples of restrictive practice such as “not paying for activities” “not allowing young people to go out at any time of the night” and “not driving young people wherever they want to go, whenever they want to go.”

What you told us the challenges are…

Survey respondents indicated that there are “[…] many grey areas for which there are limited or no guidelines or training when working with high-risk and at-risk children and young people”. This has left therapeutic residential practitioners having to make ad hoc decisions, often questioning themselves and feeling responsible for the outcome.

Our greatest challenge, then, is to clarify what restrictive practice is across TRC. How the survey respondents decided what restrictive practice was, is detailed in the graph below. Respondents could select more than one answer.

Survey responses raised the following observations:

The following are direct quotes shared by survey respondents about the daily challenges and realities of restrictive practice in residential care:

• “The use of physical restraint is a particularly confusing area for staff, particularly when a child’s behaviour is putting themselves or others at imminent risk of harm.”
• “Balancing safety with actions like restricting access to sharps.”
• “From my external experience of a range of clients / different workers can have very different understandings of what they can and cannot do, resulting in further confusion, anxiety and distress (i.e. externalising behaviours) for the young people in their care.”
• “It seems dependent on what the managers think at the time and how they feel about the child and their fear of reprisal for themselves.”
• “I think it can be a grey area particularly between different participants and different levels of risk.”
• “Often upper management make decisions based on one child’s wants to either avoid potential conflict and issues and without taking into asking how it affects the other residents.”
• “Restrictive practice implementations are used as a reactive ‘being seen to do the right thing’. This too often devolves into the inappropriate use of force – partly driven by worker feeling isolated and overwhelmed and poor management responses to behavioural issues rather than being a proactive planned and documented approach everyone can learn from and follow.”

The next steps for the CETC

The CETC has commenced developing a practice guide, “Understanding and Applying Restrictive Practice in Therapeutic Residential Care”, and continue to invite comments from the industry before finalising for free distribution. Accompanying the guide will be two short training sessions.

Based on the survey feedback and identified staff needs, the CETC additionally intend to reflect the following practice issues in the guide:

• Relevant legislation (Duty of Care, worker safety) and the interplay of this legislation.
• What a restrictive practice is and is not, and how plans work.
• Support and ongoing care for residential workers following violence or frightening incidents.
• Being able to identify early warning signs of escalation and enact strategies that can help to defuse a situation before it escalates and ensuring the use of restraint as a last resort.
• Understanding and responding to behaviours that workers may find challenging.
• Include practical, real world, 2024 examples, including technology, internet, phones, use of clothing to prevent access to body, over the counter products to help with sleep (melatonin gummies), and decision tree to help practitioners.
• Use of visuals that are helpful to understand what restrictive practice is.
• Young people’s role and understanding of restrictive practices, exploration of the impact, as well as participation in care planning.
• How the environment and resources contribute to the need for restrictive practices and their impact on other young people.

Thank you to the practitioners, supervisors, team leaders, specialists, trainers, case managers, and psychologists who took the time to complete the survey. We look forward to sharing the practice guide and support training with you later this year.