Strategies which maintain safety and ensure the effective running of wards are coming up against the challenge of two key documents. The Department of Health’s Positive and Proactive Care; reducing the need for restrictive interventions considers issues around restraint, seclusion and rapid tranquillisation and, in particular, demands reduction strategies. As well as describing those interventions, the revised Mental Health Act Code of Practice also addresses blanket restrictions – the practices, interventions and rules that we often apply to all service users, when they may only need to apply to some (such as search, limiting access to risk items or activities, etc.).
To a certain extent, we only have ourselves to blame; Positive and Proactive Care came as a result (in large part) of an RCN Congress resolution passed in 2013; unforeseen consequences, eh?
The bottom line is that we must closely examine any rules, limits or restrictions that we put in place, however well-intentioned. We need to be sure that they are reasonable, necessary and proportionate. And we also need to be sure that they are routinely reviewed, to ensure that they are still necessary. Because a particular patient used a pot mug to self-harm five years ago, do we still need to be drinking tea from plastic cups, especially since that patient went on to be discharged a few weeks later?
And the rules aren’t always obvious. Some are set from on high; they fall to earth as policy and procedure. Others are set by ward teams, and some by service users. And, more often than not, they all make sense. But we need to keep checking and re-checking. We know about most rules, but do we know them all? I’ll bet that any ward has some that the ward manager doesn’t know, even though all the patients do.
Clear boundaries can make ward teams feel reassured, more in control. But for service users, it can lead to disempowerment and a sense of helplessness. The voices of service users and their carers (rightly) grow louder, and their power to influence can feel challenging, even threatening, at times. I work in a medium secure service, as the lead for security I just love clear physical, procedural and relational boundaries. And this ‘de-restriction’ movement hasn’t always felt like it suited me or my practice. But though there are potential pitfalls, the benefits do tend to become apparent.