Analysis of Restrictive Practices in Australian Mental Health Services

This essay critically examines the use of restrictive practices, specifically seclusion and restraint, within Australian mental health services. It explores the historical context, current legislation, and the impact of these practices on both patients and healthcare professionals. The discussion covers the negative consequences for consumers, including feelings of fear, humiliation, and loss of dignity, while also acknowledging the perspectives of nurses and the challenges they face. The essay reviews initiatives aimed at reducing restrictive measures, such as the Safewards program, and the role of registered nurses in advocating for person-centered care. It highlights the tension between patient safety, the need for person-centered treatment, and the ongoing efforts to minimize and eradicate the use of restrictive practices within the Australian mental health system, referencing relevant studies and policies.

Running head: Restrictive practices in Australian mental health services
Restrictive practices in Australian mental health services
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Restrictive practices in Australian mental health services
Introduction
Seclusion and restrictive practice have been used in the health care settings in the
psychiatric and mental health unit for controlling patients with aggressive and violent behaviors.
However, evidences show that these approaches have negative impact on both the consumers as
well as the healthcare professionals. Although, Restrictive practices are perceived as the only
way of restraining a consumer’s behavior with violent behaviors, it has been found to be
associated with negative impacts on the consumer’s life. Seclusion and restraint are measures
currently allowed to monitor or regulate the actions of an adult in mental health services. Severe
concerns have been raised in Australia at least since 1993 about the use of this reclusion and
maintenance (Haugom, Ruud & Hynnekleiv, 2019). Acute medical facilities are a difficult
environment in today's Australia's Mental Health System, where a high proportion of patients are
admitted accidentally, for example 57% of the Victorian hospital admissions for 2016–2017 have
been involuntary. It is reported that 2-3% (around 600, 000) of Australians have a condition of
extreme insanity or depression and that about 0.5% have certain types of psychotic disorder,
which are mostly diagnosed with schizophrenia (Brophy et al., 2016). State or territory has
legislation on mental health which allows people with severe mental health problems to be
detained for mandatory care with strict criteria. Seclusion and restraint are interventions
commonly allowed for the intent of handling or monitoring a person's behavior in mental health
and other environments. Seclusion usually refers to an individual's conscious isolation alone in
the space or place he or she is unable to escape. The implementation of seclusion is controlled by
the mental health laws of each State or territory.

Restrictive practices in Australian mental health services
Discussion
The impacts of seclusion to consumers and healthcare professionals alike:
Significant concerns have been raised in mental health services at least after 1993 about
the use of seclusion and mechanical control. Consumers and caregivers are primarily voicing
negative perceptions of seclusion and restriction while at times finding certain advantages for the
coercive procedure and are reluctant to accept the measures as therapeutic (Brophy et al., 2016,
Kinner et al., 2017). In previous studies involving patients with input about their experience in
hospital services, several barriers have been established to deliver services that lead to consumers
' safety and treatment needs. Patients complain that hospital care facilities are custodial and
sterile, have rigid and subjective guidelines and are not consistent and conscientious to patients.
Consumers complain dull, overwhelmed and anxious and that workers have no time to engage in
counseling (Fletcher et al., 2019). Nurses articulate a wide variety of points of view on isolation
and retention: from fear, avoidance and approval of even therapeutic intervention. Reports also
reported adverse observations of serious physical injury as well as questions about the denial of
rights, conflict of personal integrity and loss of dignity. Many reports have acknowledged
negative consequences for the seclusion and mechanical repression of persons and have raised
concerns regarding violations of human rights. Consumer physical retention and containment
encounters, which have been recorded to be extremely negative, are related to acute worsening of
anxiety and intense feelings of fear, humiliation, panic and anger. The patients were stated to
experience: afraid, nervous, agitated, powerless, embarrassed and vulnerable; lost, rejected,
disqualified and ignored. Before, during and after accidents, harms have been experienced. Many
comprehensive implications include: a sense of injustice, retribution and impotence. There have

Restrictive practices in Australian mental health services
been a small number of consumers reporting negative interactions that reflect poor practices of
seclusion and maintenance, including patronizing contact. In another analysis, participants
reported that both the workers were disciplined and discarded for' non-professionals' (safety /
advisors) in particular (Prophy et al., 2016). A small number of studies, or a subset of
participants in the study, indicate positive opinions such as: that seclusion was a therapeutic tool,
or that the use of retraction has a calming effect. The security and protection of seclusion rooms
and the fulfillment of their physical needs were acknowledged by patients in other report.
Ultimately, the negative effects will mask variations in perceptions, people and climates. In this
sense, there could be significant differences between bad and best methods and the impacts that
might be correlated with them. In this context, consumers carers, experts and policymakers have
given greater attention to use of seclusion and restriction. One of the main guidelines of the
Australian Mental Health Commission (2012) in Australia are "to minimize harmful behaviors
and work to eliminate alienation and attachment." And, in New Zealand, Te Pou Te Whakaaro
Nui, the NCRI, laid out a plan for "best practice" to improve however eliminate mental health
(Brophy et al., 2016). In the Australian Institute of Health and Welfare, reduction in the use of
seclusion and confinement was reported (Australian Institute of Health and Welfare, 2018).
Seclusion, physical and mechanical control are still common practices but recent studies have
pointed out considerations such as the repeated use of these techniques with the same users
(Oster et al., 2016) or for long-term stretches (McKenna et al., 2017). It illustrates the critical
need for employees working with the customer in hospitals and EDs to better understand the use
of these procedures and interactions.
The Restraint and Seclusion in Mental Health Services Policy was thus, developed by the
Government of South Australia with the aim to provide staff with information for implementing

Restrictive practices in Australian mental health services
SA Health Restraint and Seclusion Reduction Policy Directive and direct them to practice by
adhering to legislative requirements and guide the development and implementation of
decreasing seclusion and restraint programs and ensure to maintain the individual’s rights and
dignity while seclusion or restraint is used. This policy, therefore, include guidelines that include
recommendation for training of staff, effective strategies for preventing seclusion and restrictive
practice, examining strategies for limiting potential trauma that restraint and seclusion may
create and preventing further occurrences of its use (Sahealth.sa.gov.au, 2018).
The role of the registered nurse in collaborating with consumers to work towards
State/Territory and National initiatives in reducing seclusion and restraint:
Regardless of calls for elimination and proven efficacy of reducing measures Seclusion
and isolation tend to be used in clinical and emergency environments. Nurses from across
Australia conducted an online survey which explored their views on the absence of exclusion,
physical restriction, and mechanical restriction, as well as their expectations and influencing
factors. Nurses indicated that they operate in units where physical restraint, confidentiality and
technical restriction have been used to a lesser extent (Gerace & Muir‐Cochrane, 2019). The
removal of mechanical restriction was seen as more an option than a seclusion or physical
restraint to be deemed much more beneficial than mechanical maintenance. Conflicting
respondents contributed to the elimination of ties with consumers by using these approaches.
They also thought that the use of isolation was caused by a lack of resources Empathy and the
interaction between workers and clients and the use of trauma-informed values involved aspects
considered to minimize seclusion / restraint chances. Nursing staff encountered a scenario of

Restrictive practices in Australian mental health services
danger and felt relatively safe at work, but figured that they could use their clinical skills to
maintain safety.
In mental health facilities, violence and aggression are highly complex issues; therefore,
multipurpose approaches to minimize and alleviate violence are required. Safewards is a pattern
of evidence to deter incidents that can cause violence and aggression. Effectiveness research on
Safewards adoption has shown mixed results, including a shortage of personnel engagement and
commitment in adopting policies (Kennedy et al., 2019). Although Safewards has proven to be
effective in minimizing restrictive measures, which can render things physically and emotionally
healthier, the lack of restrictive controls alone is not a healthy market climate. More can be done
to build hospitals that provide citizens with a type of sanctuary.
In the United Kingdom, the Safewards program was created to minimize' conflict
incidents' and discriminatory procedures and to improve safety (Fletcher et al., 2017).
Throughout Australia, the concept has proven a successful means of reducing seclusion and
provides, together with its behavior, a realistic basis for building true sanctuaries by specific and
tangible initiatives (Kipping, De Souza & Marshall, 2019).
A study by Muir‐Cochrane, O'Kane and Oster (2018) has found that the nurses generally
expressed great concern of the possible elimination of restrictive procedures and saw themselves
criticized both for the use and effect of these activities. Examples of the challenges encountered
by workers to account for the need to ensure safety for all involved when delivering personally-
centered services. Nurses identified the evolving position of the nurse in acute environments,
relying more on risk assessment and therapeutic resources and attempting to maintain trauma-
informed, person-centered approaches.

Restrictive practices in Australian mental health services
Little research has been done to investigate the opinions of Australian mental health
nurses on removing restrictive measures. This is relevant as study from other countries
undoubtedly represents different "political, clinical and therapeutic patterns" (Wilson et al.
2017), which influence the use and restriction of seclusion as well as the possibility for removing
these practices. In fact, research focuses on the perceptions of nurses towards the use, and their
opinions on raising the use of seclusion and maintenance. Little is known about the opinions of
nurses on decreasing the use of seclusion and restriction in mental health care, apart from a
recent Australian national survey of carers, consumers and health professionals, revealing
diverse views on the desirability and viability of removal, specifically from health professionals
(Kinner et al., 2017). With the push to remove restricting procedures, it is essential to understand
the viewpoints of nurses considering their key role in both the use of seclusion and restriction,
and in the implementation and development of approaches for reducing or eliminating their use.
Person-centered treatment was defined as a key principle in clinical practice, either
specifically related to (e.g.' client location at the centre') or implicitly relating to person-centered
procedures such as monitoring, reflecting on the person's needs, collaboration, being emphatic
and compassionate, delivering one - to-one caring, and continuousness of care. Restrictive
activities is viewed as being contradictory to the values of nursing care.
In cases where a consumer became hostile and/or offensive, nurses defined the use of
seclusion and restriction as acceptable to protect the health. Notwithstanding the overall
perception of seclusion and restraint as representing the nurse's position to maintain a safe
atmosphere, these procedures were identified as stressful for both consumers and staff (both
physically and emotionally). Recognizing the pain of seclusion and isolation indicated the nurses

Restrictive practices in Australian mental health services
understood the need to minimize such procedures. Furthermore, for people suffering from mental
health problems, nurses recognized the importance of trauma-informed nursing strategies and
were well competent in their use. Nevertheless, the dynamic and growing complexity of the
world in which nurses work has made it necessary to continue having such procedures at their
fingertips in order to maintain health. It exacerbated their concerns that it would remove
seclusion and discipline. Also, it is challenging for nurses to reconcile this vulnerability adversity
with the delivery of person-centered treatment, specifically because the nurses have less time and
ability for providing such services for consumers of mental health. Mental health nurses are
known to have an increased workload, specifically in relation to paperwork and research that is
indirectly related to patient treatment. Mental health nurses became deeply anxious and
concerned about how they could manage aggressive or violent conduct without restrictive
measures, and about the ability to be criticized for adverse events. Australian and international
attempts to continually minimize and eradicate seclusion and restriction continue to be strong,
but security issues remain central in inpatient care. The tension between person-centered
treatment and the use of restrictive risk management mechanisms is an important issue that arises
from these results, recognized in other research and especially as causing moral distress in nurses
(Muir‐Cochrane, O'Kane & Oster, 2018).
Earlier research seeking consumers input on their interaction of hospital services
established several obstacles in providing services that meet the needs of patients for treatment
and care. Consumers complain that workers are custodial and sterile, with rigid and unreasonable
laws and lack of consumer confidence and consideration. Consumers experience frustration,
annoyance, anxiety and no room for therapeutic interaction. Tension between RN and consumers
and sometimes between consumers and other patients involves these difficulties. Such pressures

Restrictive practices in Australian mental health services
that contribute to disputes including violence, substance use or absence, which could lead to the
use of restricting measures, often referred to as containment. Containment strategies like
seclusion and detention and the use of coercion have negative consequences for customers and
those who see them. The United Nations Convention on the Rights of Persons with Disabilities
has also stressed condemnation of restrictive practice policies. Safewards is a concept and series
of 10 operations that are designed to enhance protection, by minimizing tension and containment
for consumers and workers, and attract large interest, as an initiative that can minimize the use of
restrictive procedures. Multiple factors influence confliction and control in acute hospital
settings, according to the Safewards model. The model suggests a linear relationship, which
precipitates an ignition point in the source contexts, which can then cause confrontation events
that may end in containment. Conflict-containment partnership is mutual because the use of
containment will contribute to further conflicts. The model suggests also that workplace
variables have an effect at all stages. Patient modifiers may influence procedures prior to or after
a flashpoint, and patient modifiers may rely on personnel modifiers. Safewards makes a
difference in psychiatric hospital service for patients. Safewards will, however, continue to be
important. There was a major lack of consumer input from the initial development of the
interventions (although consumers were surveyed in order to select which procedures they had to
undertake) and heavy dependence on published literature to establish the concept and
interventions may cause Safewards to look backward (Fletcher et., 2019).
Conclusion
Most consumers complain that hospitalizing mental health institutions are custodial,
incompetent and lack therapeutic relationships. Hospital care consumers are insecure and need

Restrictive practices in Australian mental health services
professional and empathetic support. Internationally, sadly, patients record a number of
detrimental encounters of discriminatory procedures in their hospital care. These harms may lead
both during and after admission to suicides. Consumers and advocates were also highly worried
about the harm caused by these activities. Australia supports and delivers public sector mental
health services to assist people having severe mental health problems in its six territories and two
federal governments. These consumer experiences are relevant given the international policy
guidelines which require recovery-oriented practice. Safewards is both a concept and a series of
strategies designed for improving consumer and staff health. Positive results have been reported
for reducing the seclusion and restrictive practice.

Restrictive practices in Australian mental health services
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