Restraint minimisation in mental health care: legitimate or illegitimate force? An ethnographic study

Abstract

Coercive practices, such as physical restraint, are used globally to respond to violent, aggressive and other behaviours displayed by mental health service users1. A number of approaches have been designed to aid staff working within services to minimise the use of restraint and other restrictive practices. One such approach, the ‘REsTRAIN Yourself’ (RYS) initiative, has been evaluated in the UK. Rapid ethnography was used to explore aspects of organisational culture and staff behaviour exhibited by teams of staff working within 14 acute admission mental health wards in the North West region of the English NHS. Findings comprise four core themes of space and place; legitimation; meaningful activity; and, therapeutic engagement that represents characteristics of daily life on the wards before and after implementation of the RYS intervention. Tensions between staff commitments to therapeutic relations and constraining factors were revealed in demarcations of ward space and limitations on availability of meaningful activities. The physical, relational and discursive means by which ward spaces are segregated prompts attention to the observed materialities of routine care. Legitimation was identified as a crucial discursive practice in the context of staff reliance upon coercion. Trauma informed care represents a potentially alternative legitimacy.