Restrictive practice in the context of relational security

In SEE THINK ACT 2nd Edition, we made an important connection between the management of boundaries and the issue of restrictive practice.  These days when we’re discussing boundaries as part of relational security development sessions with clinical teams, restrictive practice almost always comes up.


There’s often an unmistakable sense of anxiety about ‘restrictive practice’ (particularly for nursing staff, the group who find themselves continually managing boundaries) to the extent they feel restrictive practices are something to be eliminated and should never exist.  It’s made some people uncertain and that’s limiting their confidence to manage boundaries, particularly procedural boundaries.


In secure mental health services, we know some restrictions are essential for the safe and effective delivery of care; and if they’re essential, then they must also be therapeutically justified and properly understood by staff, patients and those people with a stake in their care.  This means understanding what rules are in place and why, properly explaining them, and challenging them regularly to ensure they continue to meet the needs of patients.  This sounds straightforward in principle but many people working in our services would like to be more confident about the issue of restrictive practice.  Greater confidence might avoid a misinterpretation of the philosophy that results in a worse overall experience for patients. 


Here’s a recent example of misinterpreting the principle:  In a boundaries development session I ran with an MDT, a point arose about TVs in bedrooms (TV comes up a lot).  I asked what time patients were encouraged to turn their TVs of and go to sleep.  The response I received was vehement. Patients were never asked to turn their TVs off, indeed many patients watched TV until 3 or 4 am.  “We can’t” they cried, “That’s a restrictive practice!  It’s a blanket rule!”.  But another member of the group (who worked in Education) pointed out that the same people watching TV until very late were the same people failing to turn up to their jobs.  The psychologist pointed out that barely anyone attended therapy sessions in the morning and even those that did later in the day were often difficult to keep focused.  In this example, a failure of confidence in applying sensible restrictions was having the unintended effect of actually extending the length of stay of a patient in a restrictive setting.  To me, in this case, there’s a clear therapeutic argument for limiting access to TV overnight in order that patients can take advantage of the clinical programme available to them and minimise their length of time in secure care.  This example also highlights the value of facilitating relational security development with a clinical team (rather than to a roomful of random delegates) where these kind of practical issues can be revealed and dealt with.


As part of SEE THINK ACT development sessions with clinical teams, we sometimes find it useful to address the issue of boundaries and restrictive practice together.  Discussions about boundaries are always animated, engaged and illuminating; most people still feel boundaries is the biggest challenge but there’s still not enough opportunity to talk about it.  But what this session also often exposes is boundaries over which there is confusion about whether the rule even still applies, why some rules are in place at all and who’s allowed to review rules that no longer feel relevant.  There’s a clear connection here between these rules, patient satisfaction and relational security.  If we don’t know the rules, how on earth are patients supposed to?  If why don’t understand why some rules and restrictions are in place, why should we expect patients to comply with them or consider them ‘therapeutically beneficial’?  If patients feel some rules have no rationale other than to simply control them, are we surprised they want to leave?


So, in some boundary sessions we talk practically rather than just theoretically – and we write it down. Not only do we write down what boundaries and rules exist in our services and whether we feel they’re non-negotiable, negotiable or in the grey area (up for discussion), we also define why they’re in place.  We question whether that reason is still therapeutically valid and highlight the ones that needed scrapping or at least reviewing again. Here's an example:

What this accomplishes for staff is to build a proper narrative about the clinical rational for some of the necessary rules we have in place and the confidence to apply them.  What it does for leaders is to build a framework by which they can test the continued applicability of a rule or boundary to make sure it's still relevant to the clinical strategy.  And for patients, it might not always mean they get the answer they’d like but at least they and the people interested in their care receive a proper explanation for some of the rules we have in place that are otherwise sometimes pretty difficult to figure out.


See Think Act states;

“Whether ward rules are relational or procedural, fixed or flexible, they must never be punitive and always applied reasonably. They should reflect the current clinical strategy of the service (that means regularly checking whether rules that have been in place for a while are still needed) and never be purely in place for the convenience of staff.  Unnecessary or insensitively applied rules create feelings of mistrust and resentment, which leads to conflict and confusion on a ward, and makes it difficult to provide the care our patients need”.

Elizabeth Allen