Nicole Lee wants de-escalation training to be mandatory for all health workers. Credit: Rohan Thomson
When Nicole Lee threw a plastic cup of tea at a wall at the Northern Hospital in Melbourne’s Epping, by her own admission she had “lost touch with reality”.
Lee’s weight was dangerously low. She had fasted for two weeks and underwent emergency surgery after a self-harm incident. Her brain was starved, she says, and she tried to escape.
In response, two security guards shackled her arms and legs to a bed for six hours. The restraints remained fastened to the bed for the next three weeks, and were used multiple times when Lee became agitated.
“I’m not a big woman. I’m an incomplete quadriplegic. I don’t know why my legs were tied down,” Lee said. “It could have been avoided.”
Nicole Lee was shackled to the bed for six hours at the Northern Hospital.Credit: Nicole Lee
Lee is president of People With Disability Australia and spends her days advocating for disability policy reform. Knowing the system, she was shocked by the hospital’s willingness to use force, and dismiss her concerns.
“One minute I’m being restrained, not listened to, gas-lit by a service,” she says. “A couple of weeks later, I’m in Canberra speaking with Bill Shorten on the NDIS.”
The Victorian government has committed to eliminating restraints in mental health facilities within 10 years. The Australian Medical Association opposes this, citing danger to healthcare workers. But Lee says nationally consistent and mandatory de-escalation training for all healthcare workers can reduce the need for restraints, protecting patients and staff.
Experts claim over-use of restraints remains prominent in Victorian hospitals, where under-staffing and poor training makes force the default option. In its recent annual report, the state’s mental health watchdog identified inappropriate use of restraints as a “significant concern”, with 52 complaints received in the year, most of which were from emergency wards.
Nicole Lee says restraints are still being over-used. Credit: Nicole Lee
‘System gaslighting’
Three years earlier, Lee attended the same hospital in a different capacity.
Representing the Victorian government’s victim advisory council, she delivered a speech to a room packed with doctors, nurses, social workers and hospital executive staff.
Lee started by sharing her experience of living with both a physical and mental disability and how this factored into her reliance on her abusive former husband.
For years, David Latham was Lee’s primary carer and abuser – routinely raping and beating her for 10 years until the authorities intervened. Latham was sentenced to prison for these crimes but for Lee, the psychological scars remain.
At the Epping hospital around August 2019, she spoke of the need for medical staff to listen to patient experiences and incorporate this into their treatment.
“Your role is vital,” she said, according to notes of the presentation. “Look at the individual and possible barriers, ask direct questions, validate what you see and hear [and] don’t be part of the system gaslighting.”
This is a position that University of Tasmania senior lecturer Dr Yvette Maker says is supported by a growing body of evidence that women, particularly those living with disabilities or history of abuse, are more likely to be traumatised by restraints.
“Being aware of that history, by having conversations around what might trigger people, might assist the person to be calm and relaxed and feel safe,” Maker said. “All of that requires appropriate staffing levels, skills and training.”
Lee’s speech was met with rounds of applause.
However, in March this year, when she presented to the emergency department with severe symptoms of anorexia nervosa – she says none of these lessons had been learnt.
“I was treated poorly, spoken to badly, dismissed and told, ‘We have real sick people, can’t be bothered dealing with you’.”
‘Work to do’
Restraints can be used lawfully to prevent “imminent and serious harm” to the patient or others, only after “all reasonable and less restrictive” options are exhausted. Laws that govern these practices are intentionally vague which experts say leads to over-use.
“Victoria has among the highest rates of restrictive practices nationally,” says University of Melbourne expert Piers Gooding. “There’s a lot of work to do.”
Emergency ward nurses, who could not be named because they are not authorised to speak publicly, said over-use was rife in under-pressure wards and training was unevenly rolled out. Hospitals enlisted private security companies to assist, with these staff more quick to use force.
Gooding said hospital staff are not required to assess the patient’s physical strength in determining whether it’s appropriate to use restraints, but this may contribute to whether the treatment is considered “reasonable”.
“What’s reasonable for a person who has quadriplegia and is slight of weight is going to be different from someone who is six foot tall and weighs 140 kilograms,” he said.
A report published by the Universities of Melbourne and University of Technology Sydney last week found use of restrictive practices breach international human rights obligations for treatment of people with a disability and strip people with disability of dignity – including by inflicting trauma, pain, harm and violation. The report outlined an eight-point plan for eliminating restrictive practices, ranging from making them illegal to implementing a national redress scheme.
University of Melbourne’s director of the Centre for Mental Health Nursing, Bridget Hamilton, says training around restraints and de-escalation is not part of nursing degrees but rather designed and implemented by individual hospitals. Hamilton said this, combined with staffing shortages and the increasingly casualised hospital workforce, created inconsistencies in training.
The Northern Hospital was particularly exposed to staffing pressures, Hamilton said, given its burgeoning and low socioeconomic population.
“Emergency departments are not terrific destinations for people in mental distress,” she said. “The Northern has been pinpointed as an area that needs more resources. That’s happening but it takes time.”
Maker says restraints can be traumatising for hospital staff as well, adding that it’s important to remember the issue is complex, and threshold for the use of restraints varies from one situation to the next.
“It’s not straightforward,” she says. “It’s not just a simple matter of changing the law and everything will follow.”
Australian Nursing and Midwifery Federation secretary Lisa Fitzpatrick said it was important to “get the balance right” to ensure restraints are used only in situations where there is “strong evidence” to justify their use, and advocated against a “blanket ban”. “Safety of staff and occupational violence and aggression is a significant contributing factor as to why people no longer want to work in the health profession.“
‘They dismissed me’
Earlier this year, Lee called an ambulance when her symptoms of anorexia nervosa started to pose a threat to her life. However, when she arrived at the emergency ward, she says staff failed to check her vitals and did not recognise the severity of her condition.
“I lost it. I was coming to them for help, they dismissed me. I went to a bathroom and self-harmed, wanting to end my life,” she said.
The attempt on her life was so severe, Lee required surgery. The operation was bumped off the surgery list for three days, she says, which meant she needed to continue fasting. It was after this surgery that her mental health reached crisis point. “They’re unequipped to deal with that, so the first thing they do is go to restraints.”
Lee was sectioned under the Mental Health Act, and recognises this was necessary at the time, but she says the hospital processes that led up to this point inflamed her condition – and the experience afterwards has left her traumatised.
She was placed under 24-hour surveillance yet says she received no mental health support, and private security guards monitored her room.
“There were two men restraining me, wondering why I’m in fight-or-flight mode ... If we’re not addressing the lead up to the need for restraint, we’re never going to bring down the rates in which they’re being used.”
Nicole Lee says the restraints were kept on her bed for three weeks, which she says felt like a threat. Credit: Nicole Lee
At one point, she says hospital staff injected her with Olanzapine, without disclosing what the drug was and despite it being listed as an allergy on her medical records.
Lee’s partner, Mark Holloway, said this dosage put Lee into a state of unconsciousness, a known reaction to the drug allergy that pushed her blood pressure down. “When I came to see her, she was out of it for the whole day. Completely out,” he says.
Lee said hospital staff should have engaged with her about her treatment, but instead she was met with “microaggressions” that further isolated her. She recalls nurses making comments such as “are you going to be a good girl this shift?” and “are you going to behave yourself?“, which she says indicates a lack of mental health training.
Her friend, Juliette McAleer, says she overheard one nurse calling Lee “little Houdini” for going to the bathroom unsupervised.
‘Better ways’
Eventually, Lee contacted Simon Katterl, a former colleague and advocate for mental health patients, who called the hospital to request a meeting to alter her treatment plan. On her behalf, Katterl told the hospital the current approach would cause “profound and enduring trauma” but said his request for a meeting was refused.
A spokesperson for Northern Hospital could not comment on Lee’s treatment, but said “we will always endeavour to provide the care which is most appropriate for a patient’s condition, as presented” and safety for staff and patients was “our highest priority”.
Katterl helped Lee draft a letter to Victorian Mental Health Minister Gabrielle Williams. “My mental health will only deteriorate in this setting,” the letter stated. “I am not seen as a whole person, they don’t see Nicole Lee. They see a mental health patient that needs to be managed.”
After this, Katterl says there was a change in Lee’s treatment, but stressed this option is not available to other mental health patients. “Very few people who are having the same experiences as Nicole have a line to the minister,” he said. “How many people are not being heard?”
A spokeswoman for the minister said Lee’s letter was received, and passed onto the state’s chief psychiatrist, but could not comment further.
Chief Psychiatrist Dr Neil Coventry was also unable to comment about Lee’s treatment, but a spokesman issued a general statement.
“We are dedicated to transforming our mental health system and upholding the rights of every person receiving mental health treatment and care through our health services,” he said.
“The new Mental Health and Wellbeing Act 2022 lays the foundation for delivering a reformed mental health system and will strengthen the regulation of seclusion and restraint.”
For Lee, this progress is too slow. Reform targeted to mental health wards misses emergency departments and medical wards that act as “gatekeepers” to mental units, she says. Next month, she will attend the United Nations to speak about the need to deinstitutionalise mental heath care.
“People in crisis need care, not Tasers, not guns, not to be physically restrained,” she says. “When I have a mic in my hand, I’m listened to, given applause, but as soon as I become the patient, all of that goes out the window.”
For help, call Lifeline on 13 11 14.
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correction
An earlier version of this story stated the Australian Medical Council opposed the elimination of restraints. This is incorrect. The Australian Medical Association opposes it.