Critical Analysis of Restrictive Practices in Mental Health Services

This essay critically examines the practice of seclusion and restrictive practices within mental health services, evaluating their impact on healthcare professionals and patients. It delves into the rationale behind these practices, highlighting the negative consequences such as psychological trauma, violation of ethical principles, and compromised patient-staff relationships. The essay discusses the role of registered nurses in collaborating with consumers to support State and National initiatives, such as the Safewards model implemented by the Victorian government, to reduce conflict and containment. The analysis emphasizes the importance of patient-centered care, trauma-informed approaches, and collaborative strategies like active therapeutic communication to minimize the adverse effects of restrictive practices and promote positive patient outcomes. The essay concludes by advocating for a shift towards less restrictive interventions and improved therapeutic relationships within mental health settings.

Running head: MENTAL HEALTH
Mental health
Name of the student:
Name of the University:
Author’s note

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Restrictive practices such as seclusion and restraint are common intervention in mental
health to manage aggressive or violent consumers. However, due to the negative consequence of
this practice on staffs and consumers, there has been an international drive towards reducing or
completely eliminating the use of this practice in mental health (Muir‐Cochrane, O'Kane &
Oster, 2018). Various programs and efforts have been implemented globally to reduce the rate of
seclusion and restraint events for patient. However, the issue is that this practice has not yet been
curtailed off and restrictive practices continue to be a part of mental health care. Due to such
widespread support for eliminating this practice, it is paramount to understand the rationale for
this (Hext, Clark & Xyrichis, 2018). Thus, to develop knowledge in this area, the main aim of
this essay is to critically discuss about the practice of seclusion or restrictive practices in mental
health services and evaluate its impact on health care professionals and patient. The essay will
further discuss the role of registered nurse in collaborating with consumers to support work
towards State/territory initiative and National initiatives.
The use of restrictive intervention is debatable in mental health practice. However, it is
still used in Australian mental health settings just like other countries. Seclusion involves
confining a person alone in a room where contact with other individuals are prohibited, whereas
restraint involves restricting freedom of movement of a person by using physical or mechanical
means (Jackson, Baker & Berzins, 2019). Patient with mental illness and their carers in Australia
have advocated against this restrictive practice because of the infringement of human rights and
compromising the therapeutic relationship between staff and patient. The Australian Mental
Health Commission calls for leadership across range of priorities to address the issue. To track
reduction efforts, many health agencies and Committees in Australia has collaborated to record
data on seclusion, mechanical and physical restraint and track reduction in rate of restrictive

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practices as part of quality improvement agendas (Australian Institute of Health and Welfare,
2020). The regulation of restrictive interventions is now legal under The Mental Health Act 2014
and the Victorian Government has shown commitment to reduce this restrictive interventions too
(Victoria State Government, 2020). There are several reasons for the National and State
government to take action on the issue and this is explained further in the next paragraph.
Both health consumers and staffs have poor attitude towards seclusion and restraint in
mental health. This has been seen from review of several research papers evaluating and beliefs
about the practices from consumers, carers and mental health care professionals. An online
survey done in Australia regarding interpreting views of consumers on seclusion and restraint
practices revealed that majority of participants had negative views about the process because of
its potential for causing harm to patient, breaching human right and compromising trust (Kinner
et al., 2017). The level of harm to patient through the use of seclusion is understood from review
of the experiences of these patients. A study by Ye et al. (2019) investigating about the impact of
restraint in mental health settings reported that patients going through physical restraint
experience have gone through severe psychological trauma. For example, they suffered from
feeling of low self-esteem, extreme distress and re-evoking of childhood sexual abuse triggers. In
the long term, these experiences have resulted in low quality of life and loss of hope for affected
individuals. These experiences in turn will further worsen the stigma and negative affect
adherence to medical treatment too. Thus, when weighing the benefits of the intervention
compared to cost, it has been found that seclusion is associated with more harm than benefits for
patient.
In addition to psychological trauma associated with restraint, another reason behind
disapproval of restrictive practices among consumers as well as staff is that it is associated with

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violation of ethical principles of autonomy, justice, beneficence and non-maleficence (Campos &
Rezende de Oliveira, 2017). According to the ethical principle of patient autonomy, it is
necessary to support individuals to take their own decisions and staffs have the duty to respect
autonomy of patients. However, maintaining individual autonomy becomes difficult for nurse
and leads to ethical challenges for them. For example, when a nurse faces patients with
aggression, it is their responsibility to protect other patients by using seclusion. This action is for
public benefit, however as patient’s wish is not respected and this done against force, patient
autonomy is violated. As restrictive practices do not consider the unique need and perspective of
patient, it is also said to be in violation of patient-centred care (Zheng et al., 2019). Moreover,
the Universal Declaration of Human Rights emphasizes the need to promote equality and justice
for all. However, secluded patients have reported about not being able to receive equal nursing
service as other patients as they are treated badly and secluded in rooms with poor condition
(Haugom, Ruud & Hynnekleiv, 2019). Thus, review of these experiences show how restrictive
practices can rob patients from their inherent rights to be treated with equality, integrity and
dignity. The experience is associated not only with traumatic experience but also destruction of
patient’s relationship between patient and nurse. A post-seclusion review by Muir‐Cochrane,
Baird and McCann (2015) suggests that nurses or mental health staffs often regret or complain
regarding the negative impact of such practices on staff-patient relationship.
Many mental health consumers are in favour of removing seclusion and restraint
practices as they have suffered because of this too. The study by Haugom, Ruud and Hynnekleiv
(2019) has expressed that the need to use seclusion has been associated with extreme distress due
to decision making challenges for mental health professionals. They have expressed feeling
insecure while using this practice as many patients attack them during the process and they get

4MENTAL HEALTH
harmed physically. Other staffs have expressed nervousness because of decision making conflict.
This is because restrictive practice has a thin line with patient beneficence and autonomy. It
becomes difficult for nurse to weigh threats, violence and safety against self-determination.
Although staffs are compelled to prioritize safety over patient self-determination, very few staffs
are able to handle the situation in an ethical and professional manner. The heightened case of
ethical dilemma is a common cause of stress for care providers. However, instead of highlighting
the negative aspects of using seclusion, many research studies have come up with suggestions to
improve experiences of patient post seclusion or restrictive practices too. For example,
Hammervold et al. (2019) highlighted the significance of rigorous debriefing in reducing the
psychological trauma and its impact on overall recovery. The article also introduced recovery
oriented suggestions such as emphasizing on personal recovery and taking crucial steps to
maintain hope even during crises. The utility of such recovery oriented or trauma informed
services must be considered in the context of Australian state like Victoria.
In response to the call for reducing restrictive practice, one of the initiative that have been
implemented by the Victorian government to control use of seclusion and restrictive practice
include the implementation of Safewards and the adoption of recovery oriented models during
the process. The Victorian government has embraced the Safewards models and associated
intervention as a strategy to reduce conflict and containment. It is a multifaceted approach that
has been developed after series of empirical research. The main feature of the Safewards model
is that it emphasize on bringing back a shift in focus towards direct care and building therapeutic
relationship with patient. This model has ten associated intervention to reduce conflict and
containment events (Victoria State Government, 2019). Fletcher et al. (2019) revealed about the
benefit of this intervention in several countries. An evaluation of the Safewards intervention

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across 18 wards in Victoria revealed a significant reduction in conflict events and positive
attitude towards staffs regarding the acceptability of this practice change initiative. However, as
this practice is dependent on collaboration between staff and patients, evaluating the
consequences of such action is paramount.
The review of research literature revealed the adverse effects of seclusion on patients as
well as staffs. However, negative impact such as psychological trauma and sense of distrust
could have been avoided if the staffs had take approach to maintain therapeutic relationship with
patient even after the use of seclusion. For example, Haugom, Ruud and Hynnekleiv (2019)
suggest the role of debriefing with patient after the use of seclusion so that trust is restored.
Immediate staff debriefing has been found as an effective intervention to help staffs support each
other after a distressing event. As the Victorian government has implemented the Safewards
initiative, the registered nurse could be trained to play a vital role in collaboration with the
patient. The nurse role is most important as they are in close proximity to patients and they are
the largest group of health professionals in mental health settings (Mangaoil, Cleverley & Peter,
2018). They contribution can be vital to enhance the success of Safewards approach. The
Safewards approach mainly encourages the staffs to intervene before patient reaches the point of
emotional distress. Hence, the goal is to apply the best containment method for the situation. It is
focused on recovery based goals as the intervention proposed creating an environment that is
peaceful for patients with fewer assaults and injuries. The nurse can use their collaborative skills
to foster relationship with patient and minimize the adverse consequences of seclusions (Victoria
State Government, 2019).
According to Bowers et al. (2014), the utility of the Safewards model is that it identifies
six domains that leads to conflict and containment. These domains include patient community,

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staff characteristics, team work, the physical environment, the regulatory framework and the
outside hospital. It is an initiative to enhance patient-centred care during mental health care. This
is relevant to use of restrictive practices in mental health because patient-centred care is seriously
violated during such practice. The registered nurse use of patient-centred approach and trauma
informed framework can help them to embrace least restrictive practices (Muir‐Cochrane,
O'Kane & Oster, 2018). For example, while using seclusion or restraint, instead of leaving the
patient continuously in a separate room, the nurse can engage in the practice of positive words by
saying something positive to patient during each interaction or explain patient about the factors
contributing to difficult behaviour. In addition, registered nurse can enter into collaboration with
aggressive client and calm them down. Such patient-centred collaborative care can lead to
empowerment of patient and positive ward level outcomes (Goulding et al., 2018).
Registered nurse in Victoria can adapt various patient-centred approach like active
therapeutic communication with patient and sharing of clear mutual expectation to slow the
down the practice of restraint. The nurse must critically think about factors that triggers stressful
event and maintain patient’s rights by asking their preference for containment use. This form of
activity can reduce patient autonomy violation issues and support nurses to make proper safety
plan for mentally ill patients (Hamilton et al., 2016). This initiative can be utilized by nurse to
take vital training in the area of conflict prevention and reducing restrictive practices too. Such
training would lead to a renewed understanding about the relation between conflict and
containment. Better knowledge about the relationship will increase nurse’s confidence in
listening well and talking respectfully to consumers. Collaborative steps like active listening,
empathy and open communication is the key to minimize frustration among patients and break
the cycle of conflict and containment. Initiatives like Safewards are beneficial for mental health

7MENTAL HEALTH
staffs too as it can increase the motivation and support for staffs to engage with consumers in a
therapeutic manner (Fletcher et al., 2019).
To conclude, the essay discussed about the issue associated with the use of seclusion and
restraint and the adverse impact it has on patient. By the critical review of literature, it was found
that seclusion not only increases psychological and physical trauma for patient, but also lead to
conflict due to violation of their ethical rights. In addition, due to high ethical dilemma and
resistance by patient during the process, staffs also face challenge in the use of such practices. In
an effort to reduce or control such practice, the essay reported about the effectiveness of
Safewards initiative by the Victoria government which aims to reduce seclusion by improving
patient-centred care. The registered nurse role in clear communication, understanding about
conflict and containment and taking the approach to seek preferences from patient at important
points of care can be effective collaborative steps to move forward with the Safewards initiative
and control use of seclusion.
References:

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Australian Institute of Health and Welfare (2020). Mental health services in Australia. Retrieved
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australia/report-contents/restrictive-practices
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Haugom, E. W., Ruud, T., & Hynnekleiv, T. (2019). Ethical challenges of seclusion in
psychiatric inpatient wards: a qualitative study of the experiences of Norwegian mental
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