Restrictive mental health practices in the management of acutely unwell patients

Author: Eimear Muir-Cochrane

Muir-Cochrane, Eimear, 2022 Restrictive mental health practices in the management of acutely unwell patients, Flinders University, College of Medicine and Public Health

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Restrictive practices such as seclusion, physical, mechanical, and chemical restraint are commonly used in acute mental health and other inpatient settings and remain a wicked problem in the ongoing quest to reduce their use. This thesis focusses on the use of restrictive interventions in adult inpatient units as a significant issue in the ongoing care of people with a mental illness and other inpatients (exhibiting acute agitation, aggression or violence), and its effect on their experience of hospitalisation. Laurence (2003) stated that the continuation of restrictive practices in psychiatry would be condemned in any other area of medicine and many stakeholders have called for at least their reduction while increasing numbers of consumers and carers call for their complete elimination. Individuals who find themselves inpatients in acute mental health and other services deserve to receive the least restrictive care possible as a basic human right, and not to experience trauma or be re-traumatised as a result of hospitalisation.

A PhD by Prior Published work (PhD PP) is significantly different to a traditional PhD in that the published papers stand both independently and collectively as the body of research and are allowed to speak for themselves, as it were. The eight published papers are situated within this thesis which systematically explores historical, legal, ethical and clinical issues relating to seclusion and restraint. The dynamic tension between safety and risk is examined to demonstrate how restrictive practices are perpetuated in inpatient settings. The consumer experience and the evidence regarding contemporary restrictive practices is presented with an examination of the basis of specific models designed to reduce conflict and containment in acute psychiatric inpatient settings. The eight published papers include the topics of risk assessment and clinical decision-making, absconding, seclusion and restraint, chemical restraint, and the role of security guards. The research settings include aged care acute psychiatric units, adult acute psychiatric units, Emergency Departments (EDs), and acute and medical-surgical units, with all the research conducted in South Australia. The Safewards Model (Bowers, 2014a) is adopted as a discursive tool to discuss the implications of the eight papers within the current literature and suggest further research to tackle the wicked problem of restrictive practices.

The collective impact of various forms of restrictive practices as a whole (in the context of the period of hospitalisation) needs to be recognised and understood as greater than the sum of individual restrictive practices which frequently have a profound and enduring negative impact on inpatients. The paradox of providing care in the context of the use of restrictive practices remains both a perennial issue and a significant problem facing health professionals working in the care of people with an acute mental illness. Multi-factorial interventions developed through co-production with consumers and carers are required at every level of mental health services if transformative rather than incremental reformist change is to be achieved in the reduction of the use of restrictive practices. Significant barriers remain to transformational change to facilitate the reduction and elimination of restrictive practices and while elimination of such practices is echoed in international and Australian policies and initiative, this goal remains elusive as safe practical alternative clinical practices do not currently exist.

Keywords: mental illness, psychiatric inpatients, restrictive practices, seclusion and restraint

Subject: Health Service Management thesis

Thesis type: Doctor of Philosophy
Completed: 2022
School: College of Medicine and Public Health
Supervisor: Professor Sharon Lawn