Reducing restrictive practices: a union agenda

Mick McKeown, UNISON’s National Nursing and Midwifery Occupational Committee academic member addresses the use of restrictive practice in mental health settings, the effects it’s usage has on staff, the impact on the therapeutic relationship between staff and patient and what possible solutions exist to reduce levels of compulsion and coercion.

On top of the adverse effects of the COVID-19 pandemic a decade or more of austerity policies have seriously impacted upon the levels of mental distress in society and the resources available for mental health care. Right now, the government is consulting on a White Paper about changing Mental Health law in England and Wales, with the other devolved nations having their own legislation. This White Paper has foregrounded the minimisation of restrictive practices as a key pillar of proposed change. So, what is meant by restrictive practices, what is the importance for nursing professionalism and union organising, and what can be done about them?

Restrictive practices can take many forms, can be subtle or obvious, and are commonplace across mental health services, especially inpatient settings. They are not independent of each other and, indeed, efforts to reduce one set of practices can simply mean use of others increase, unless a more sophisticated approach to systems change is brought to bear. These practices are legitimated by mental health law and include:

Compulsion into services and subsequent limitations to liberty, for instance not being able to leave a ward.

Seclusion – confining a person into a space away from other people, typically a closed room, which can be purposely spartan, with minimal furnishings to avoid risk of injury.

Forms of restraint of the person. This can involve physical restraint – holding a person so that they cannot move freely; chemical restraint – immobilising a person with sedating medication; or mechanical restraint – restricting movement with straps/belts, handcuffs or restraining garments such as straight-jackets. Mechanical restraint is used more frequently elsewhere in the world, but also in parts of Europe and North America. Despite being rare in the UK, you may be surprised to know it is still found, with many hundreds of instances of its use noted in the NHS last year alone.

Other forms of coercion that place limits on aspects of everyday life. In the extreme this can involving forced treatment against the will of a person but softer forms of coercion can include persuading individuals to accept a degree of limitation or lack of choice because the threat that more extreme coercion is available is implicitly understood or explicitly mentioned in persuading compliance.

Though such restrictive practices are usually thought of with reference to mental health care, they are clearly not only an issue for mental health services. For example, young children can be held whilst receiving treatment such as injections, confused older adults may be nursed in beds with cot sides or in tip-back chairs, and physical restraint may be widely used in services caring for people with learning difficulties. Indeed, some of the more egregious abuses of such restraint were uncovered in the shocking events at Winterbourne View, a private hospital for adults with learning difficulties where undercover filming exposed widespread malpractice eventually leading to mass sackings of staff and the closure of the facility.

Despite the potential for misuse of restrictive practices, the focus here is on concerns about the minimisation of the legitimate use of these approaches. Research shows that use of coercive and restrictive practices can damage therapeutic relationships and physical restraint, in particular, can result in various injuries, psychological and physical for both patients and staff. Even witnessing the use of restraint or forced tranquilisation can be detrimental for people and operate to further undermine therapeutic relations and spoil the general atmosphere and emotional climate on a ward. It is, however, worth noting that these matters are complex. People subject to restrictive practices can at times see their value, even if this is with benefits of hindsight, for instance in terms of protection from harm in a context of vulnerability for instance, people might disavow their use for themselves but want staff to use on others and, even where staff interventions are objected to, the perceived procedural justice of their application is crucial – how fairly or justly are these practices dispensed?

It seems quite clear that most nurses do not go into a job in mental health wishing to coerce people or be involved in forced treatment, restraint or seclusion, rather they are motivated by compassion and concern for people experiencing mental distress. Hence, the most obvious forms of restrictive practice are thought of as interventions of last resort; a ‘necessary evil’ to be reserved for situations of pending or actual violence or deranged, out of control behaviour where a means of safely restoring calm is urgently required. To find oneself caught up in such situations can be extremely stressful for nursing staff and others and the idea that inpatient settings are the sites of increasing concentrations of violent and out of control individuals is a proposition that can be difficult to argue with. What is less easy to understand but may be helpful in navigating our way to solutions, are the various factors which might play into a scenario of escalating violence and associated anxieties. Through better understanding we may be able to enact more thoughtful responses, including preventative measures. We must recognise that the politics of austerity that feed high levels of conflict also obstruct attempts to resolve it. This is most obviously related to insufficient resourcing of safe staffing levels, but also the underfunding of

supportive training and poor built environments all play a part. Awareness of the role of such factors can help us frame professional and trade union demands for targeted and universal resources to address relevant issues, providing a better foundation from which to build services grounded in consensual rather than coercive relationships for everyone’s benefit.

A number of initiatives have been developed in an attempt to minimise use of restrictive practices. These include Safewards, No Force First, 6 Core Strategies and REsTRAIN YOURSELF. All of these initiatives have demonstrated positive reductions in use of restrictive practices across a variety of settings and different national contexts. They all build change at the level of whole teams, focus upon strong, positive relationships and attempt to engage service users in meaningful activities. Among many examples of good practice, Tryweryn Ward, Betsi Cadwaladr won the 2019 Nursing Times Team of the Year Award sponsored by Unison. These approaches result in better working environments for our staff, more peaceful relationships with service users and greater job satisfaction. Hence, both the mental health workforce and people who use mental health services have a shared interest in reducing levels of conflict in mental health services.

Despite previous policy commitments to community care and related attention to mental health laws, levels of compulsion and coercion have actually increased year on year since the last reform of the Mental Health Act in 2007. Associated with this are intolerable levels of conflict on mental health wards which often necessitate the use of various restrictive practices, including physical restraint. This state of affairs results in physical and emotional injury for staff and service users. High levels of conflict, violence and aggression are bad for staff and service users. Furthermore, both staff and service users would prefer not to be involved in restrictive practices; to neither use nor be subject to physical restraint. The good news is that we do have knowledge of how to reduce restrictive practices and addressing the relevant complexity of factors involved is both a professional and trade union matter that we can all get behind.

Last year, Unison’s Nursing and Midwifery Occupational Group submitted a motion to this effect to health conference, which was unfortunately postponed because of the COVID-19 restrictions. We are discussing with our Group our response to the consultation on reform of the UK Mental Health Act and will support measures in it aimed at reducing the use of restraint. We fully intend carrying forward this work, and anticipate that the union will eventually resolve:

  • to campaign alongside other organisations and service user groups for more investment in the reduction of restrictive practices
  • to promote and share good practice across the NHS to reduce the use of restraint and improve staff wellbeing
  • to campaign for investment for staff to have the time for such initiatives