Restrictive practices in secure mental health services

Restrictive practices aim to manage the risk of harm presented by service users in healthcare settings. They are intended to be last resort methods in secure services when less restrictive options of risk management have been exhausted, as they are known to result in harmful consequences for people who experience them. Despite the recognition that their use needs to be reduced and the efforts that have taken place to try and achieve this, they remain a prevalent international issue. The aim of this thesis was to address this problem and further explore restrictive practice use in secure mental health settings, by reviewing the available literature (chapter 2), identifying service type and service user factors through quantitative analysis (chapter 3), as well as using Grounded Theory to identify staff decision making processes (chapter 4) associated with the use of seclusion.

Findings were synthesised into an integrated model that aimed to explain the use of these practices, as well as provide a framework to address the problem (chapter 5). The next aim was to test the model by evaluating interventions to reduce restrictive practice using a case study (chapter 6) and a quasi-experimental study (chapter 7). Restrictive practice use is a complex, multi-faceted phenomenon and seclusion use differs between services and service user presentations. Staff decisions to use restrictive practices are mediated by cognitive, emotional, relational, and organisational factors. Restrictive practice use seemed to serve different functions in different services, and a ‘one size fits all’ approach to reducing them is therefore unlikely to be successful. By targeting numerous factors identified in chapter 5, encouraging results were observed in a case study that included reductions in restraints and behavioural incidents (chapter 6), as well as some reductions in the frequency and duration of restrictive practices following ward-based interventions (chapter 7).