Nurses Perceptions Of Restrictive Practices Assignment Sample

Nurses Perceptions Of Restrictive Practices Assignment

Chapter 6: Discussion

6.1 Introduction

This chapter provides a clear and critical discussion of the previous chapter where all the findings from the research have been elaborated. The efficacy as well as limitations of the design strategies along with possible restrictions regarding this research are considered. The chapter delivers a brief discussion on the themes, interviewers’ opinions regarding various questions, some justification behind the approach of restrictive nursing practices, and a reflection on self-learning from the accumulated information. Although there are several controversies and dissimilarities in the information provided by these nurses due to their different point-of-views, this chapter builds a connection between these different perceptions. The “qualitative description research strategy” has been adopted to discuss the restrictive practices by nurses in different forensic secure units. Furthermore, various relationships have been tried to build among different factors such as the relationship between the positive effects and negative effects of restrictive practices, or the effectiveness and relationship between experienced-based practices and evidence-based practices. Furthermore, in this chapter, the initial findings are examined to compare with the interviewees’ responses.

In the concept of restrictive practices among nurses, the emergent themes from the previous chapter reveal various factors that are the outcomes of the conducted interview. The participants’ responses are evaluated which reveals a total of five themes related to this context. Each theme consists of sub-themes. Participant responses’ evaluation process has been categorized into individual group discussion and focus group discussion. The responses to the interview explain the opportunity of current rules, help in recognizing the rules’ effectiveness for both patients and staff, the relevance of the rules, and also help to challenge some beneficiary rules for the staff. 

During the analysis of the interview responses, several factors are identified which are more important regarding the context. These factors are related to nursing planning, policies, rules, and healthcare facilities that can provide enough support to improve the restrictive practices of nurses. In this case, the concern of patients is the most important criterion in this practice. These factors open some opportunities in the regulations to provide better treatment to the patients. Furthermore, there are various rules which are applied to the patients although they have negative effects on them. Group discussion provides various important information regarding this context.

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Rationale

In this assignment, the various types of restrictive practices are highlighted in medical sector. The necessities and the proper method of using those practices are mentioned (Antón-Solanas, et al. 2019). These help us to understand the advantages and disadvantages of using those practices. There are various types of risks that are associated with the amount of restrictive practices. To take control over patients, multiple restrictive practices are necessary to implement else patients can be out of their control which may result in severe damage or injury to other patients or nurses.

6.2 Discussion

Significance of care and control

Out of the five themes which have been recognized from the interview responses, the most important theme is care and control which illustrates a common understanding related to restrictive practices and their importance in medium forensic secure units. This theme is mostly applied to the men’s medium secure wards (Selekman et al. 2019). Providing safety to all the stakeholders along with proper care is very much difficult to balance as it is often seen that when one patient gets proper care and safety, other patients may be deprived of proper care. Hence, it is difficult to provide care to all patients equally. 

In the forensic secure units, patients are of different types with different necessities, risk factors, importance, etc. Each type of patient needs different care, which is hard to provide to all patients individually. To provide better services, these forensic secure units are categorized into three different parts viz. acute admission wards, rehabilitation wards, and medium or high dependency wards. Each ward has different importance. In the case of acute admission wards, patients having a severe or short-term mental illness are admitted in these wards (Lincolnshire Partnership Foundation Trust, 2020). They require proper care from the nurses with great attention as they are highly sensitive. The rehabilitation wards mostly consist of people who require general support with extra care to recover their mental health issues and become independent. Nurses need to provide proper care to the patients in these wards to fulfill their necessities. Lastly, the medium or high-dependency wards are very much crucial that require intensive care in all environments (Kalkan U?urlu et al. 2021). Patients admitted to these wards are more dependent on the nurses to perform their regular activities alongside controlling their anger issues [Referred to Appendix 1]. 

In the case of care and control, the major limitations are the staff group, shortage of staff, and requirement of staff during an emergency. These affect the care provided to the patients. In the secure units, patients are instructed about do’s and don’ts from the initial stage which further limits the activities of the patients (Barr et al. 2019). While providing care, the major focus should be the supply of proper treatment to the patients and supervising their activities to assess if there is any bad effect on their performed activities. Nurses need to identify those bad activities which are harmful to the patients and should focus on setting strategies that can assist them to reduce those behaviors. A proper care plan needs to be developed for the improvement of the patients seeking proper care (Blackwood et al. 2019). A restrictive care plan provides numerous restrictions on the activities of the patients which can help in the improvement of the patients. In most cases, the restrictive care plan fails to fulfill the objective as this can often fail to meet the patient’s needs and some of the restrictions are harmful to the patients.

Concern regarding community leave

The community leave is one of the important policies of restrictive nursing practices. This helps in the development of the patient’s mental condition. It is very often that there is a risk of degrading the mental state of the patients while they are unable to connect with the outside world for a long time, or unable to attend any family occasion or event. For this reason, patients are allowed to discharge from custody to visit their families or any important occasion (Gray et al. 2019). Furthermore, this community leave also helps to assess the patient's current state of mind which also reveals the effectiveness of the treatment. 

From an interview with a male nurse, it is known that plan-of-the-day meetings are important for every patient which can help them to select specific activities for the whole day. These meetings evaluate the mental condition of the patient on a regular basis. Furthermore, these meetings are important to access community leave. Because without assessing the mental condition of the patients, it is impossible to discharge them in society otherwise this can result in serious injury or accidents (Tomlin et al. 2020). Regularity of the patients during the meetings provides various opportunities to patients for obtaining community leave. 

From the interview with a dual-trained nurse, it is known that empowerment of patients can be obtained through different social activities such as permitting them to do the shopping for themselves. The restrictive practice also requires the treatment of chronic illnesses such as diabetes because it can affect the mental condition of the patients (Government of the UK, 2021). Furthermore, in this practice, it is important to focus on the patient’s lifestyle choices along with practices consisting of health behavior and this decides the improvement or deterioration of the health condition. 

In addition, exercise can improve the mental and physical health of a person. For this reason, the significance of exercise is high for these patients. The participant also emphasizes exercise activities that can improve their health. In the case of patients with chronic disease, special attention needs to be provided that can reduce their illness. For instance, diabetic patients are required to provide necessary assistance via sugar or carbohydrate to maintain the sugar level in the bloodstream (Poghosyan et al. 2022). The caregivers need to monitor the activity of patients with chronic diseases to check whether their activities are harmful to their health or not. 

Introduction of regulations to reduce smoking activity

Furthermore, the smoking activity of patients is also harmful to patients. To reduce their smoking activity, especially on the hospital premises, the non-smoking policy is an effective solution. This prevents the patients from smoking in the hospital. It is important to monitor the behavior of this type of patient for which the 'community leaves’ for this particular group of patients are not applicable or less applicable. According to a participant named Lynnette, reducing bad habits can be positively impacted by empowering patients to limit their practices. There is also a craze for e-cigarettes among patients (Hawkins, and Hacker, 2022). This e-cigarette is introduced to patients to reduce their tobacco consumption. This also improves the environment of the hospitals by converting them into non-smoking places. Although e-cigarettes are the most popular alternative for the reduction of smoking activities, smoking e-cigarettes is also prohibited in communal places, ward courtyards, and bedrooms. This regulation has been implemented to reduce the bad effect of passive smoking on other non-smoker patients. 

The use of community leaves for maintaining smoking activity is done by tobacco consumers. As the longevity of e-cigarettes is lesser than actual cigarettes, patients are more intend to consume the original cigarette (Parraga, and Morissette, 2020). Another reason behind not consumption of e-cigarettes is the financial factor because these cost more than normal cigarettes. The role of nurses in reduction of the smoking behavior is somewhat controversial because they cannot force the patient to stop smoking instead they can advise and request them to not smoke. The final decision taker is the patient himself/herself. This reveals that nurses are fully aware of their jobs and the basic rights of humans. Hence, they do not intervene in the decision-making capability of patients.

Blanket Rule

Blanket rules refer to the practice of following a certain rule which applies to everyone. Hereby, the restrictive rules are agreed upon by the participants. As the participants stated that the restrictive practice will the men in medium secure service involved food. Among the participants, Adam stated that in his administration ward, one rule is being followed for the restricted patients which restricts consuming food after 8 p.m. Here Ezra interrupted and stated claimed the act was a fundamental human rights vitriol. This situation creates a certain argument that says when one patient has their dinner early at 5 p.m., they obviously will get hungry at 8 p.m. then Bella added they could have been given a lightweight food such as toast or some fruits at 5p.m and then they can serve the dinner at 8 p.m. As a reply, Adams said that the Blanket rule should not be implemented for everyone and no one can state that there is no more food (Bifarin et al. 2022). This situation where the law is held creates a space for argument and disagreement at the same time [Referred to Appendix 2]. 

If the Blanket rule is implemented for every individual patient, they will not feel comfortable or it may hamper their human rights basics. Then again Bella continued with there is some staff who are yet in a paradox where they assumed that patients don't have the right to consume hot drinks after 10 p.m. or have food after 8 p.m. Adams added that they used to keep all the tea bags and sugar away at 10 p.m in his ward. Bella added that the same was used to happen in her ward also but now that rule has been changed (Liddell et al. 2021). However, after shifting their building to a new upgraded modern facility, any patient can access the hot water at any time. Where staff on the other side monitoring hot water was not a roaring factor for the staff in the daytime. Daniel joined the conversation and added that the regulated temperatures which reduce the dangers of being burned. Bella said caffeinated drinks are still restricted on her ward. So that no patient has access to take caffeinated tea or coffee. Alex agreed to this and added, after 10 p.m. the only allowance for the patients is to consume decaf tea and coffee. It demonstrates that every ward contains a different prospect for separate interruptions. 

Emma & Ezra declared on their ward, there are no such restrictions on consuming caffeinated drinks or hot drinks. In their ward, handling the mobile phones of the patients are a difficult job as considered. They said that there is a certain time for the patients when they can access their mobile phones. On this statement, the rest replied that, in their ward, mobile phone is considered a secure medium and not accessible (Doyle, and Clark, 2020). This analysis demonstrates that every ward has its policy and they are accountable to maintain those.

Restrictive practices in respectably forensically secure units

All the participants spoke plainly about the significance of consenting to approaches and rules and Moderate security controls. They added standards and rules to assist patients with understanding their limits and if they try to violate these rules then the consequence will be significant. The staffs assume that this practice will keep the ward contained and safe. Also, they added that the restrictive practice will help high-risk patients. Among all the patients most of the patients have been admitted to the hospital due to committing serious crimes and all are being transferred from prison. There are various types of risks that are associated with the amount of restrictive practices. To take control over patients, multiple restrictive practices are necessary to implement else patients can be out of their control which may result in severe damage or injury to other patients or nurses which was supported by Maguire et al. (2021). Thus several implications of restrictive practices are necessary to maintain stability inside the ward. The consideration has to be safe to get a better understanding of the service users which is more important than the crime that they have committed. Restrictive practices in medium-secure settings can sometimes be beneficial in establishing procedures and frameworks, but they can also create antagonism and instability when patients believe they are always being handled by rules and restrictions. Most of those present concurred that the less restrictive techniques should be used by nurses wherever possible.

Proper treatment according to the law

In the forensic secure units, patients are treated according to the requirements and on the basis of the mental health act applied to that patient. Various patients possess different levels of threats. Patients accused of 37/41 are treated under a strict environment where their activities are compromised. The court directs the hospital to put more restrictions on these patients. On the other hand, patients accused of 47/49 are advised to shift from prison to hospital. Hence, the practice which is applied to a 37/41 patient is very much different from a 47/49 patient as their threat levels are of different kinds (McSherry, and Maker, 2021). Their legal acquisition also reflects on their leave applications. A patient of 47/49 can get a leave as he/she possesses less threat to other people or society while a 37/41 patient faces several difficulties to get a leave of their own choice. This punitive measure is supported by the majority of the nursing staff as this is directly related to the mental health act. Patients having a personality disorder or bipolar disorder often face difficulties in following care plans which further restricts their activities in the hospital. These types of patients are under strict observation as their decision-making capabilities are affected. Bernice and Robert’s words are in support of these punitive measures. On the contrary, some nurses go against these behaviors as they do not support putting restrictions on all personal choices of patients. Their anti-perception regarding this context is somewhat irrelevant as the court instructed the hospital to perform such punitive practices to reduce those patients’ level of threat. A different participant argued that the prerequisites for restricting practices must exist. She also stated that they must be beneficial, constructive, & accompanied by an explanation regarding the motivation (Government of the UK, 2023). Collaboration is therefore two-way. The person does not just presume that everyone is aware of why one is unable to do something at that moment; they truly grasp it. Some nurses inform that several of these restricted practices are used by staff members without a lot of rationales. They cited an instance of personnel refusing to let patients consume hot drinks past midnight or forbidding them from making phone calls at specific hours, even when they were phoning friends or family in another time zone.

Another respondent maintained this with a model that happened in the mid-year, when patients and edge leave for regular air inside the center grounds was not worked with in light of an absence of staff. 

About staff issues

The interview with Robert has revealed that the major issue behind the restriction of granting leave is the insufficiency of healthcare staff. Due to less amount of staff in the care centers, individual monitoring of the patients is hard to perform. For this reason, the patients are not allowed to go outside the hospital premises. There is a high risk for patients who has criminal records or are in the continuation of their imprisonment. In both of these situations, there is a chance of escaping if proper monitoring is not provided. Patients can easily escape from the hospital premises due to poor monitoring of staff (Parke et al. 2019). This indirectly affects the mental health of other patients because they are looking for fresh air due to long-term confinement in the hospital premises. Disallowing them to go outside leads to their frustration. 

Requirement of sufficient nurses is also necessary for taking care of the patients properly. To monitor each patient effectively, sufficient workers are required. Insufficient workers cause high pressure on presently working workers as they have to perform all the work that is beyond their capabilities (Oates et al. 2021). In addition, a sufficient amount of workers is necessary during an emergency to control the situation and it is hard to control an emergency with insufficient workers.

Refusal issue

The refusal issue is a common factor in hospital premises. Workers are often refusing to work as instructed due to various issues such as non-compatibility with other workers, a victim of assault activity, and redeployment. Non-compatibility among staff members can lead to the development of disturbance inside the hospital premises. This also increases the chance of escaping from hospitals due to the negligence of workers (Sizoo et al. 2020). To increase the compatibility among staff, their morale needs to be enhanced which can help in developing a good relationship among them and greater efficiency in their work. 

External pressure on nurses

Patient stakeholder issues are a crucial factor that can interrupt the restrictive practices of nurses. Nurses are often pressurized by the relatives of the patients or the social workers. During the research, Webb et al. (2023) found that social workers do not value the activities of nurses inside the forensic care units, rather they create pressure on nurses to change their restrictive practices as their concern is patients’ basic rights instead of the improvement of their mental health condition. Furthermore, the activities of social workers affect various nursing practices which are implemented for the betterment of patients’ mental health conditions (Webb et al. 2023). In fact, restricting nurses to implement restrictive practices on patients often leads to injury or nuisance inside the wards where nurses are held responsible for that. During the research, Webb et al. (2023) found that social workers do not value the activities of nurses inside the forensic care units, rather they create pressure on nurses to change their restrictive practices as their concern is patients’ basic rights instead of the improvement of their mental health condition. Furthermore, the activities of social workers affect various nursing practices which are implemented for the betterment of patients’ mental health conditions (Webb et al. 2023). In fact, restricting nurses to implement restrictive practices on patients often leads to injury or nuisance inside the wards where nurses are held responsible for that. Nurses perform various activities to improve the mental health of patients such as restricting them to roam unnecessarily, smoking excessively, performing unhealthy activities, etc. It is often seen that social workers pressurize hospitals to provide all the facilities for patients and fulfill all their demands but it is beyond their imagination that patients can take these opportunities in a negative way. For instance, patients can manipulate social workers into that they are deprived of their basic rights when nurses restrict them from consuming tobacco. Furthermore, influential social workers pressurize hospitals and workers legally with the help of advocates and solicitors (Markham, 2022). Their restrictive practices often face challenges from these legal teams though these are performed for patients’ safety. 

Pressure from the patients’ relatives is of different kinds. They mostly pressurize the hospital workers for an explanation for not giving discharge or leave. For patients’ safety, their discharge or leave requests are approved on the basis of multiple factors, out of which two major factors are the criminal record of the patient and the current mental condition of the patient. If a patient has any criminal record or comes to the hospital for treatment during imprisonment, the discharge or leave request is hard to approve as there is a chance of escaping if the patient is allowed to leave (Kriakous et al. 2019). Furthermore, due to staff shortages, it is difficult to monitor the patients all the time and their requests have been rejected most of the time. 

On the other hand, the patient’s mental condition is also an important factor to determine whether they should take leave or not. Most patients have a bad habit of smoking or performing unhealthy activities. If they are discharged from confinement, their bad habits can enhance significantly, so nurses provide them discharge or leave only if their bad habits are reduced. There are also some other reasons why nurses feel pressurized. Nurses are restricted to provide leave to the patients when the ‘leave slots’ is full. In this case, patients’ relatives heavily pressurize the healthcare workers and nurses to provide their patients leave without understanding the reason behind not approving the leave requests (Watson, and Choo, 2021). These are all due to the deficiency of awareness among the patient’s relatives and social workers.

Reflective practice along with MDTs often cause pressure on nurses. In the case of MDTs, they put pressure on the nurses by restricting the implementation of nurses’ decisions regarding patients’ health. Further, MDT decides all the rules and regulations for the patients which sometimes causes serious trouble to them. The restrictions on nursing activities cause serious trouble to nurses from both sides - patients and management. If they follow all the restrictions, patients become frustrated, and if they ignore any restrictions the management will become dissatisfied (McCullough et al. 2020). In several cases, nurses perform their work depending on the facilitators’ personalities. Staff shortage also put pressure on the nurses in the forensic secure services as the limited number of nurses need to perform all the work which is beyond their capabilities. 

The outcome of the group discussion has revealed that MDT only follows the advice of psychologists but they do not care about the suggestions from the nurses and compel them to follow their decisions. Nurses often feel pressurized while implementing or not implementing some of the decisions if that is related to the patient’s mental health. Furthermore, nurses are seeking a better management team who gives importance to their words as well. As nurses spend most of their time with the patients, their perceptions, suggestions, and decisions are significant regarding the restrictive nursing practice (Jolly, 2022). Additionally, nurses have to visualize the negative effect of implementing some wrong decisions on restrictive practice but their freedom of speech is taken by the MDT which causes mental pressure on them. 

Restrictions on having food or tea also affect the morale of the nurses. The nurses are ordered not to provide any kind of food to the patients after 8:00 p.m. whether they have their dinner or not. But it is difficult to deny the demand when a patient asks for food after 8:00 p.m. as it is against their morale. Furthermore, the denial can deprive them of their basic human right. No one can control the eating and drinking of a person in any case, all they can do is request them to maintain the proper schedule (Morris et al. 2021). The interview report reveals that in men’s medium secure unit, they are not allowed to provide any food to the patients. Nurses feel difficulty in following this restrictive rule. 

Even drinking is controlled by the management in the forensic secure units. Nurses are ordered to put away sugar and tea bags so that patients cannot drink any time when they want. Even the nurses have reported that earlier the water provided for the tea was lukewarm which affects the patients’ experiences of having tea but nowadays the provided water is warm enough to enjoy drinking tea. While treating a patient in a restrictive environment, it must be assured that the patient’s basic human right should not be affected by any condition for the sake of treatment (Markham, 2023). For instance, if any diabetic patient wants to have soft drinks, the nurses are not allowed to disallow the patient to have any, and rather they can explain the consequences of having soft drinks containing sugars to the patient and suggest their opinions. The ultimate decision needs to come from the patient's side. Contradictorily, if the patient has any serious issue where drinking can significantly affect their health, in that case, nurses can interfere with the patient’s basic human rights (Collins et al. 2021). This is done to assist them in improving their health condition.

Nurse’s contribution

In restrictive practice, the contribution of nurses to the improvement of patient’s health conditions is highly significant. They are the only ones who spend most of their time with the patients. An experienced nurse can easily handle the situation in a less restrictive manner. Due to their long-term experience in this field, they can easily de-escalate situations fluently. Experienced nurses can improve any situation by verbally convincing the patients to follow the rules and assuring them to provide full support which is necessary for them to improve their health situation (Barr et al. 2019). One of the most effective ways of handling any situation is by providing an experienced nurse to each patient or providing an experienced nurse with a group of nurses to support and improve their working efficiency. 

Decision-making skill is an important part of nursing practices in which the nurses need to take a proper decision that supports the situation. Any wrong decision can lead to huge disturbance and can also affect the health condition of the patients. Due to various restrictive conditions, nurses often face frustrated patients. They effectively convince those patients in 1:1 session where all the issues of patients have been solved or promised to be solved. For this purpose, the significance of qualified nurses is huge. Furthermore, qualified nurses often handle heated conversations between healthcare providers and patients (Paradis-Gagné, and Guimond, 2020). They can calm down the patient and reduce the heated environment which reduces the chance of disruption during treatment. 

Furthermore, experienced nurses can help to deal with the medication issue. If any patient has been prescribed to follow multiple medications with strict instructions, newly qualified nurses often find it difficult to maintain the medication properly, especially if any reaction occurs due to the medication. In this case, experienced nurses can raise their voices against doctors to change their medication or provide an alternative solution to reduce the effect of medication (Stevenson, and Taylor, 2020). Due to their experience in this field, they have more power to raise their voice against the decision of doctors while the newly appointed nurses cannot do that activity as they do not have any experience or sufficient experience to explain their opinions. 

The outcome of the interview with the focus group revealed that they are uncertain about the importance of the experience in restrictive nursing practice. Some participants think that experience is necessary for daily managing the ward while others think that anyone can manage the ward with proper support from other workers. There is a conflict between old-school and new-school groups of nurses because the old-school group makes the nursing practice difficult whereas the modern group makes the practice easy by undertaking various approaches. The main reason behind this contradiction is that modern nurses perform evidence-based practices which allow them to deal with numerous situations in the workplace though they do not have any experience (Bennett, and Hanna, 2021). The absence of evidence-based practice difficult the process of nursing and increase the dependency on experienced nurses which partially creates an invisible pressure on those nurses. 

MDT does not put importance on the nurses’ opinions, but some managers give importance to the opinions of nurses as they spend most of the time with the patients. They support and respect their decisions if they are practical, commensurate, and justified. In most cases, support from higher management is missing which puts the nurses in trouble. The judgment of the nurses and their decision-making skills are often scrutinized by the senior staff which results in the suspension of the nurses (Jolly, 2022). Senior staff often accuse the nurses of taking self-decision as they do not promote the violation of their established rule. In this case, the complaints from patients’ relatives or social workers also influence the prosecution of nurses.

Evidence-based practice

Modern nursing practice is mostly based on evidence study. Evidence-based practice enhances the approach of nurses toward any situation because there is always a piece of evidence for a particular situation that suggests the course of action of the nurses to deal with that situation. The patients also support the evidence-based approach which makes it an efficient strategy to perform nursing practices in the respective field. Another advantage of evidence-based practice is that it does not require the experience of a long time to provide effective service (Goodman et al. 2020). As there are sufficient evidence-based strategies for the adverse situation, nurses only need to imply those strategies appropriately to deal with the situation which is contradictory to the old-school nursing practices. 

The evidence-based practice provides multiple models for the reduction of aggression and violence in the safe wards along with multiple sections. These sections refer to recovery, individual expectation, mutual expectation, and assurance. Furthermore, evidence-based practices provide various types of training that can make nurses efficient in working in forensic secure settings, such as forensic security training, PMVA training, and PPE responder training. These trainings assure effective restrictive practice in forensic secure settings while following the Trust policy and basic human rights law (Olausson et al. 2021). The specialized training further helps in controlling patients in the medium secure units effectively by providing proper handling techniques. 

There are multiple models provided by evidence-based data. The Safewards model is one of those models which can effectively and appropriately suit forensic secure settings. This model provides various interventions that can help in decreasing restrictive practices. This model also guides the conduct of community meetings for the patients weekly. This model mostly focuses on the patients and staff. There are a total of ten interventions in this model which are discussed with the patients, viz. soft words, wrong news migration, mutual support meetings, mutual expectations, reassurance, talk down, know each other, discharge messages, positive words, and calm down techniques (Maguire et al. 2022). These interventions help the nurses to manage patients to follow instructions and generate effective communication between the nurses and patients and help to evaluate the mental condition of the patients [Referred to Appendix 3].

The above image represents an outcome of weekly group meetings where the patients discuss multiple interventions of the Safewards model (Mullen et al. 2022). The outcome has revealed the status of the mental condition of the patients and their activities such as involvement in physical conflict, property damage, verbal conflict, and absconding. These help the nurses to determine their future strategies that can improve these conditions.

Unwanted and unexpected effects

Restrictive practices in the forensic secure unit have both positive and negative outcomes. These restrictive practices are performed only by nurses inside the ward. While performing these practices they face multiple consequences of which some facilitate the recovery of mental health while others retain the improvement of mental health conditions. As these restrictive practices are mostly developed by MDTs or higher authorities, the effectiveness of the outcomes of all restrictive practices is unknown to them (Lean, and Sims, 2022). The interview of different nurses has revealed that there are many restrictive practices that are not helpful. For instance, nurses feel pressurized when they have to restrict patients to have their dinner or breakfast at their own will or restrict their drinking behavior just to maintain safety. These types of behaviors are unwanted for nurses inside the forensic secure units. The people have several issues while maintaining these restrictions as these practices affect their basic rights.

Unexpected effects come from the patient’s end when these unwanted restrictive behaviors are implied to the patients. The long-term restrictions on the behaviors cause frustration in the patients. Patients become riskier as they disagree to follow the rules (Haines-Delmont et al. 2022). Furthermore, patients’ mental health conditions also deteriorate when they continuously follow these restrictive practices. Furthermore, patients become angry with nurses when they force them to follow such restrictions although nurses have no choice but to follow those restrictive practices as instructed by their seniors or MDTs. These unwanted practices and their unexpected outcomes affect the work experience of nurses and they feel frustrated about their work. This further affects the health care system of the forensic secure units (Hayward et al. 2023). This is a significant reason behind the shortage of sufficient nursing staff as they are aware of such pressures and adverse environments.

6.3 Justification for restrictive practices

During focused group discussion, several questions were put to the participants which explored and justified by them. For instance, when the participants were asked about restrictions that are not helpful, several gave an example of restrictions on having a shower after 8:00 p.m. This directly hurts their basic rights and this type of restriction is not helpful for the patients. This restriction is customized according to nurse requirement and are not focused on the patient’s needs. These type of restrictive practice is not suitable for patients and many nurse have raised their voice against such restrictive behavior. There is no such proper justification for this restrictive rule which was established by MDTs. There are several instances of increasingly restrictive practices in the forensic secure units when there is less staff. To compensate for huge pressure on the staff due to staff shortage, several practices such as restrictions on roaming, leaving, maintaining a particular time for common activities or actions, etc. are opted (Tomlin et al. 2020). These help the existing nurses to perform their work efficiently and manage all the patients together without facing many problems.

This study aims to obtain an understanding of nurses' opinions of restrictive practices and their implications for the nursing profession. The term "restricted practices" in nursing refers to any activity that restricts a nurse's autonomy, such as mandated clinical documentation formats, mandatory technology usage, and other policies. These actions can have negative impacts on a nurse's autonomy and capacity to deliver high-quality care, along with on the general standard of nursing care given (Von Bogdandy and Villarreal, 2020). Therefore, it is critical to understand how nurses view restrictive practices in order to spot and manage any potential problems. The purpose of this study is to uncover any potential problems with nursing's restrictive practices and to assess how they affect the profession as a whole. The study's findings can be applied to improve nursing practice by addressing any potential problems or misunderstandings regarding restricted practices along with by learning more about nurses' perspectives of these practices. 

• Patient safety: Restrictive practices are often utilized to shield patients from harm, especially in situations where they may represent a gamble to themselves or others.
• Staff safety: Nurses may use restrictive measures to safeguard themselves and other healthcare providers from aggressive or brutal behavior by patients.
• Treatment efficacy: now and again, restrictive practices can uphold the delivery of successful treatment, guaranteeing patients get the necessary care while limiting potential dangers.

Restrictive practices are medications used in healthcare settings to manage challenging behaviors or guarantee the safety of patients and healthcare professionals. While these measures may be deemed necessary in certain situations, it is essential to examine nurses' impression of restrictive practices, including their justifications, problems, harmful effects, and potential models and approaches to reduce their implementation. Nurses play a crucial job in managing restrictive practices, and their discernments greatly impact their implementation and impact on patient care. While justifications for restrictive measures may exist, it is important to acknowledge the problems and harmful effects associated with their use. By embracing models and approaches aimed at lessening restrictive practices, healthcare professionals can advance patient-centered care, maintain ethical standards, and enhance the prosperity and safety of the two patients and healthcare providers. Through continuous education, multidisciplinary collaboration, and a pledge to ceaseless improvement, nurses can add to a healthcare environment that prioritizes dignity, autonomy, and optimal patient results.

Given that nurses are the frontline healthcare providers, it is crucial to comprehend their viewpoints and ideas in order to best serve patients with high-quality treatment. Thus, this study will be a significant source of knowledge that can be applied to the creation of future healthcare improvement plans (Tu and Recht, 2019). Indicator violations influence decisions about restrictive practices. Recently, assorted images have been important in restrictive nursing approaches to mitigate the adverse effects of restrictive attitudes, including Safety Assemblies, Safety Ward Models, and Relationship Security. 

During individual interviews, the participants were asked about the significance of restrictive practices in medium forensic units, on which participants have suggested their opinions and also express their anger against some of the restrictive approaches. According to Participant 1, restrictive practice is highly crucial for the medium secure unit as the patients inside the medium secure units are mostly unsettled and have challenging behavior. These restrictive practices act as an important tool in the high-dependency ward. In the medium secure units, the associated risks of the patients are controlled through these restrictive practices in order to control their movement and various kinds of leaves. In another word, it can be said that restrictive practices help to maintain safety in the hospital ward by restricting potentially risky patients (Sustere, and Tarpey, 2019). According to Participant 1, an inspection of the patients is done through the plan of the day and the patients who attend this are restrictive practices. On the other hand, patients who are absent during the plan of the day are restricted by the employees of the ward. Their activities are restricted for that day as a punishment for not attending the plan of the day. The participant further added that risky patients are gone for long-term locked door seclusion although sometimes each of the patients is kept in open door seclusion to deescalate them from the adverse situations and talk with them to reduce their mental stress for better outcomes. These restrictive practices are convenient to nurse because the consequences of patients’ misbehavior help them to understand the basic difference between two possibilities. Furthermore, nurses use these punishment approaches to control patients’ negative behavior so that they would not practice such behaviors in near future. It has been also mentioned that the implementation of restrictive practices depends on the patient’s current condition (Lawrence et al. 2022). A patient who threatens to attack other patients or hospital staff is kept in locked door seclusion. In this way, the risk has been terminated using restrictive practices. 

The forensic secure unit is devoted to exploring and treating people with serious psychological wellness maladjustments who are imprisoned as a component of policing. In spite of the fact that it very well may be seen as restricting the autonomy of patients, it also has therapeutic value in boosting safety, supplying structure, and facilitating therapeutic associations (Blackwood et al. 2019). One of the principal advantages of restricted practice is to safeguard the patient from hurt. Individuals with serious psychological sicknesses are in danger of hurting themselves as well as other people, and limitations might be set up to forestall such damage. For instance, a suicidal patient might be under consistent observation or may approach possibly hazardous things. Essentially, patients who show vivacious ways of behaving may really be limited or hesitant to hurt others.

Notwithstanding expanded security, limitations are helpful while working with the therapeutic framework by making a coordinated and amazing environment. In expansion, uniform timetables and rules give a feeling that everything is good and sturdy. It additionally assists clients with controlling their way of behaving. Moreover, staff has a remarkable chance to cultivate a mending therapeutic relationship with patients (Barr et al. 2019). Limitations may likewise give expected open doors to representatives to take part in medicinal exercises, like psychological wellness. According to Participant 2, a restrictive practice directly refers to the restrictions on the freedom of patients. Restrictions on freedom refer to the activities of the patients in their daily life when they are admitted to the medium secure units. Participant 2 has faced various restrictive practices where restrictions on the time are the most common practices for having breakfast, lunch, dinner, medication, and smoking (Barr et al. 2019). The participant further added that there is a biasedness in providing leaves to the patients from the wards. Patients punished with section 47/49 are restricted to stay in the ward, even though they are not allowed to leave the ward without any exceptional circumstances which are mostly for accessing healthcare services. Patients admitted with 37/41 are also deprived of getting leaves easily as they are admitted to the medium secure units as the local wards are unable to manage them with minimal restrictive practices. There is a high risk of granting leaves for them as they can run away from the medium secure services without getting discharged from their wards. Furthermore, the freedom of activity is different for different patients (Kennedy et al. 2020). Patients with a higher degree of vulnerability are restricted in every action while patients with lower vulnerability are restricted in certain actions. Restrictive practices help to recover the basic skills of the patients gradually in stages which further helps those patients to adapt those skills again.

During the interview, Participant 3 perceives restrictive practices as a method to prevent patients from activities of their own will. In the participant’s ward, the most common restrictive practices are the use of phones and permit for fresh air. The participant mentioned that most of the adverse situations have occurred in the garden while the patients go for fresh air. Due to scarcity of the staff, it is hard to monitor every patient in the garden, and as a result, the patients are restricted to use the garden for a certain time (Tully et al. 2023). On the other hand, the use of mobile phones is also restricted in the ward as the patients can contact anyone who can manage and help them to run away from the ward. As some of the patients are vulnerable to society it is harmful to allow the patients for using a cell phone. In addition, restrictive practices deprive patients of several basic human rights. With the help of the cell phone, these patients can communicate with anyone to create disturbance in the ward. For these reasons, the two restrictive practices are strictly followed which is also supported by Tomlin et al. (2020). Putting restrictions on mobile phone usage is very much necessary for the recovery process of the patients as they can access whatever they want when they use mobile phones. This can lead to potential risks where other patients or nursing staff may get affected. Furthermore, mobile phone has numerous negative effects on human mind. In the medium care units, securing mental health is the superior most priority for the nurses for which putting restrictions on using mobile phones is justifiable. The participant further added that restrictive practices help to reduce injury among the patients as the insufficient staff cannot manage all the patients at a time. The participant further added that the restrictive practice is mostly influenced due to insufficient resources present inside the ward. To manage staff deficiency a common approach seen from most caregivers is seclusion. Locked-door or open-door seclusion is the most common approach for caregivers as it is easier to control their activities (Chitty, 2020). In some cases, this seclusion causes a mental breakdown or other mental issues which can greatly affect the patients. In this case, a face-to-face conversation between the patient and the nurse is the most effective approach. 

Participant 4 perceives restrictive practices as the tool to manage escalating risk behaviors such as aggression and violence from patients. The participant has mentioned various types of restrictive practices such as chemical restraint, seclusion, mechanical restraint, environmental restraint, and physical restraint although the seclusion strategy is the most common practice. In the ward, this strategy is strictly implemented in patients with high levels of disturbed and aggressive behaviors (Cooley, 2019). This seclusion practice reduces their level of violence and aggression and helps them to recover their mental conditions. In addition, blanket restrictions are also applied in the ward in which the patients are restricted to roaming around certain places and performing certain activities. Furthermore, to control the movement of the patients within the building, traffic lights are also used. These various approaches help nurses and caregivers to provide day-to-day care delivery in an efficient manner. Vulnerable patients are segregated from other patients through restrictive care approaches. The participant further added that all the aggressive and violent behaviors of the patients are not enough to keep them in locked-door seclusion (Hansen et al. 2020). Those patients can be kept in open-door seclusion if they are cooperative with the staff inside the ward. In that case, de-escalation of the patients is easier for the staff. It is often seen that taking decisions of implementing locked-door seclusion practice is difficult for the nurses as they are not sure about the outcomes. In that cases, the nurses feel pressured. If there is an experienced nurse present on the team it is easier for them to take such decisions (Tomlin, 2020). Seclusion approach may lead to partiality against different patients but this approach is highly necessary for the safety of other stakeholders. This approach hurt the basic rights of the patients but this can be justified on the ground of safety. Many nurses use open-door seclusion to avoid hurting patients’ mental conditions although when there is a high risk of getting injured or damaged, lock-door seclusion practices are performed by them. There are certain codes of conduct that reveal that nurses should treat all the participants equally. This is justifiable for every hospital except the mental health care settings. In these mental health care settings, particularly in forensic secure units, patients are admitted with different mental health conditions and they possess different levels of risk (Flammer et al. 2020). For this group of people, the same treatment for all patients might not be effective and useful. The main reason behind this is their threat level. Patients who possess higher threat levels are bound to several restrictive approaches while patients who possess lower threat levels are free from highly restrictive practices. This may lead to partial treatment, which also disobeys the nursing code of conduct 4.1. Furthermore, partial treatment helps each patient in the improvement of mental health conditions. In the case of Participant 4.

Participant 5 during the interview put more focus on the seclusion strategy while discussing the importance of the restrictive practice in the forensic secure units. The participant has described the seclusion approach more elaborately. The information provided by the participant has revealed that the patients experiencing the seclusion strategy have various restrictions such as being non-accessible to laundry, toilets, kitchens, and bedrooms. Furthermore, they have restrictions on the consumption of food. For example, they cannot avail tea or coffee after 8 o’clock as this can affect their sleeping behavior. Apart from that, they are handcuffed during the visit to the hospital or the court. In some situations, the restrictive approaches become very intrusive as some patients, are forced to undress in front of a same-sex staff to terminate the risks (Rule, 2019). This behavior is highly affect patients’ mental health. This approach may reduce the risk of any harmful activity but on the other hand it is very much offendable in a system where patients’ mental health is given more priority. In addition, while ward searching, patients’ consents are taken before the search, and those who do not give consent are moved to another place to perform the search activities as the suspicious activities occurred. While considering the importance of restrictive practices, it is crucial for the patients because of their criminal background. The restrictive practice helps them to remain in the ward and also in their recovery. In a brief, it can be said that patients’ safety is the highest priority of the medium secure services for which the caregivers can go to any extent (Barr et al. 2019). All these searches, intrusive activities, and other things performed in the ward are mainly for the assurance of the safety of the patients present in the wards.

Participant 6 has a vast knowledge of the rules and regulations on restrictive practices along with the various categories of the practices. In the restrictive practices, various activities are performed by the caregivers, and various laws are followed such as monitoring of visitations, mental health treatment with depot medication, TESO observations level management, no smoking policy, an array of contraband/restricted products, and utilization of seclusion rooms. These are helpful in performing restrictive practices in the medium secure units. According to the participant, the patients are suffering from mental health issues for which they become vulnerable and commit crimes (Rabab et al. 2020). To retain themselves from further criminal activities restrictive practice is highly significant. During their treatment, patients’ past medical history gets more importance than their past criminal records. Their treatment requires careful consideration. As the patients are mentally unstable, it is important to treat them with more care and maintain a healthy routine for themselves. For this purpose, the introduction of restrictive practices is more important and plays a crucial role in maintaining a proper schedule on a daily basis. Various boundaries have been drawn around the patients which confined their activities to reduce the risk of getting injured (Sustere, and Tarpey, 2019). Participant 6 has also revealed that the lack of seclusion rooms in the ward affects the proper implementation of the restrictive practices and minimizes their implementation.

Participant 7 perceives the restrictive practices as certain rules and policies for mental health settings which restrict the patients and sometimes staff from specific freedoms and rights. During the interview, the participant replies that restrictive practice is helpful to provide security and safety to risky people. There are various restrictive approaches such as environmental security and protective time slots. Environmental security refers to the seclusion strategy which is specifically applied to the vulnerable patients of the wards. Based on their activities they are kept for short-term or long-term seclusion (Chitty, 2020). In the case of protective time slots, the patients are bound by time-based activities. For instance, no possession of hot drinks after midnight or not doing a phone call at certain times promote restrictive practices while providing safety to other patients. Such practices help nurses to maintain the safety of the patients at night. These approaches are performed to protect the patients from all the external and internal factors as there is a huge risk of performing such activities at an unusual time (Kennedy et al. 2020). These types of restrictive practices may affect the basic right of the patients but play a significant role in patients’ safety. 

During the interview session with the focused group inside the hospital, several questions were asked to clear and visualize their perceptions toward restrictive practices. Most focused group participants are experienced in their field and are currently appointed to medium secure units, high dependency units, and acute admissions. The questions asked of the focused group participants are similar to that of the general interview questions. The interview process is the group discussion type for this focused group of participants where all 6 participants answer the questions for the interview and share and discuss their opinion with each other. 

When asked about their perceptions regarding the restrictive practices in mental health settings to care for the patient and control their activities, Speaker 1 states that the restrictive practices are nothing but the section which restricts patients’ activities. According to the speaker’s perception, it is a good practice as it does not pose any risk to the patients. The speaker has shown optimism toward the restrictive practice. The speaker’s statement shows the good side of the restrictive practice and it does not support the individual care plan as it can discriminate against the patients. Further, the speaker supports restrictive practices such as the return of patients’ mobile phones at a certain time which can promote good sleep for them (Oates et al. 2020). Additionally, the speaker further added that there are a few disadvantages of the restrictive practices but those can be ignored as most of the restrictive practices help the patients to protect their lives.

Speaker 2 perceives restrictive practices as a crucial assessment tool for people who are potentially risky and are admitted to the high dependency wards. Generally, the patients accused of Section 37/41 are tagged as not much risk to other patients in the speaker’s ward, and thus they are implemented with less restrictive approaches (Sashidharan et al. 2019). The speaker has mentioned that in restrictive care settings, restrictive practices are normal as it is directly concerned with the patient’s safety.

Speaker 3 mentions that restrictive practices need to be performed for all patients more or less equally as individual care plans can cause discrimination among patients that leads to their dissatisfaction. The speaker also adds that there must be a balance on restrictive practices to make it useful in the medium secure units. Restrictive practices need not be implied unnecessarily, for instance, a patient who is self-harming in nature must be monitored all the time but for other patients, it is unnecessary (Levy et al. 2020). In addition, the speaker has mentioned maintaining consistency in the medium secure units to reduce problems.

Speaker 4 somewhat disagrees with the generalized care plan and put more importance on the individual care plan. According to the speaker, a patient-centered care plan can help to recover each patient more efficiently as the approaches are specific to the patients.

Speaker 5 mentions the lack of resources such as a shortage of staff, emergency staff, and staff groups. All these are related to restrictive practices. According to the speaker, the care plan for the patients can be restrictive as they are bound to certain rules and regulations which determine their activities. For instance, the speaker has mentioned the restrictive practices on the consumption of food (Thomas et al. 2020). In the medium secure units, the patients are restricted to have their food after 8 o’clock which is direct violence against their basic human rights. The speaker further added that caregivers should not be rude and should provide the patients with food if it is reasonable. The rules for not providing drinks such as tea are another violation of basic human rights. This might be convenience for a small group of nurses but a large number of nurses have raised their voice against such behavior. They have modified their practices according to their convenience as well as patients’ convenience so that it does not harm their morale or mental health.

Speaker 6 claims that restrictive approaches must be reasonable such as a specific time for using mobile phones as it can reduce the chance of unnecessary disturbance. All the restrictive approaches are made up on reasonable grounds so that other patients do not feel disturbed by the activities of one patient inside the ward (Heise et al. 2019). Furthermore, the speaker focuses on making restrictive practices more adaptable to patients.

All the speakers have claimed that their restrictive practices are not decided on their own, in fact, all the rules related to restrictive practices are established by MDT, and the nurses are regulated according to their direction.

The overall perception of restrictive practice refers to that it is an essential component of forensic secure units which are capable of controlling patients’ behaviors in the ward. There are several positive effects for which these approaches are practiced inside the wards. These restrictive practices are developed by MDTs or higher authorities to improve the mental health conditions of patients in the forensic secure units while providing security to other patients as well as nurses but these practices are not discussed with nurses while developing (Hext et al. 2018). This causes a gap between the theoretical approach and the practical approach. Restrictive practices effectively reduce the threat inside the medium secure units by restricting patients’ activities. Various activities such as maintaining a proper schedule for food consumption, no smoking activity, and short-time seclusion techniques help to improve the mental health of these patients. These practices also improve their behaviors. On the contrary, there are also some restrictive practices that cause serious trouble whether directly or indirectly. Some practices push patients to lose their independence, such as they do not roam inside the ward freely, or roam in the garden for a particular time, being unable to consume food after the specified time, being punished for long-term seclusion, etc. These practices retain their mental improvement as these are unexpected activities for them (Watson, and Choo, 2021). Furthermore, various external forces such as patients’ relatives or social workers affect the application of the restrictive approach.

For security purposes, restrictive practices also set limitations on the approval of patients’ leave. While maintaining legal orders and evaluating the mental health conditions of patients, granting leave to a patient is a difficult task for nurses. The nurses are always attentive to not become partial when it comes to providing common facilities such as providing food, medicines, etc. Partial practices may lead to dissatisfaction among patients although nurses have some special instructions to manage patients with a 37/41 tag. This is because they are a threat to other patients and staff as legally mentioned by the court. They often go under some strict restrictive approaches which are not experienced by other patients or the patients with a tag of 47/49 (Parraga, and Morissette, 2020). Sometimes while practicing restrictive activities, patients’ basic rights often get violated for their safety purpose. Some of those restrictive practices are helpful to manage safety effectively but need to be modified according to patient’s requirements. One such practice is the supply of hot water for tea. Patients are provided with hot water to make their tea only for a specified time, after that they cannot get any access to make tea further. This restriction is helpful to prevent any damage or injury as any patient can use the hot water to cause injury to himself/herself or to other patients. This also violates human basic rights. Hence, this approach needs to be modified in such a way that it provides safety while not violating human basic rights (Oates et al. 2021). The interview session provides a solution for such modification. The suggestion explains that patients can be provided with lukewarm water instead of hot water which can serve their purpose of having tea in one hand and maintain and provide safety on the other hand equally. 

In the forensic care units, during practicing restrictive activities, nurses are pressurized to apply several medications to those patients who possess high threat for a certain time. Information provided by all the nurses has revealed that the pressure from higher authorities often forces the nurses to take help of medication illegally which is serious violence to the nursing activities. Nurses are the major victim of this workforce as they have to perform various practices which they do not support morally, instead, they perform this job forcefully (McCullough et al. 2020). The consequences of their activities reflect on patients in the form of nuisance, deterioration of mental health condition, dissatisfaction, violence, etc. These various approaches affect the environment of the forensic secure units. This adverse environment causes a deficiency in the number of nursing staff as most of the nurses avoid such working environments. In addition, the higher authorities do not listen to nurses' suggestions in spite of the fact that they spend most of their time with patients. Restrictive practices are developed without taking any suggestions from nurses which is the main reason behind such disturbances. During the development of such practices, suggestions from nurses can help to increase the effectiveness of these practices (Morris et al. 2021). MDTs and higher authorities prioritize theoretical experience more than practical experience. For such reason, there is a deficiency of effectiveness when implemented in the practical field. 

Furthermore, nursing practices in these forensic secure units follow two types of approaches viz. experience-based practice and evidence-based practice. The experience-based practice provides more fruitful results than that evidence-based practice as experienced nurses have practical knowledge of the way to manage any adverse situation and they can easily identify the potential threat. On the other hand, evidence-based practice can provide a solution for a particular knowledge but fails to deliver any solution for a change in that situation (Lawrence et al. 2022). Furthermore, an evidence-based approach requires huge theoretical knowledge to understand which strategy needs to be implemented for a particular situation while experience-based practice does not rely on any theoretical evidence, instead previous knowledge of such practical experience helps to take relevant necessary actions. Hence, in the forensic secure units, experienced nurses get more priority than newly appointed nurses.

6.4 Effectiveness of design strategies

The interview has been categorized into two parts viz. individual interview and group discussion. This helps to identify the information gaps between individual interview and group discussion. In individual interview, the group discussion has assured the relevancy of the data obtained from the individual interview.

The participants are either nurse or the healthcare workers related to restrictive care which significantly increase the relevancy of the information collected. During individual interview, the information collected from each participant are almost similar that increase the acceptancy of those information. Additionally, group discussion followed by individual interview provides a complete amalgamation of each participant’s experience for a particular subject. This reveals the overall image of a particular subject/factor. The contradictory perceptions regarding experience of nurses help to evaluate the importance of experienced nurse in the restrictive system along with the significance of evidence-based nursing practices among the newly appointed nurses.

6.5 Limitations

Limitations of methods and design strategies

The whole study has been performed using mixed method approach with qualitative data. The interview portion has been categorized into two parts viz. interview of 13 participants and interview of 6 participants from the focused group. The interview data has revealed that the answers from the speakers of the focused group differs when they are introduced in the group participation.

Two parts of this interview process makes the interview more time-consuming for which all the answers of the participants are compromised within a limited time. Apart from that, taking nurses or healthcare workers as the participants causes time-related issues as they are hardly having a free time to attend the interview session. Further, during one-on-one interview process, there are some factors noticed which somehow limits the interview procedures. In some few information, there are transcription gaps noticed which slightly affect the procedure and put a question mark on the reliability of the data. In addition, for a few questions, some participants did not answer properly and hesitate while answering although this issue has been resolved during group discussion.

For instance, the number of available staff is a type of resource (Swan et al. 2018). Deficiency in the number of staff affects the services that result in implementing multiple restrictions on patients’ activities. Less number of staff affects the free-roaming of the patients in the ward. Another important resource is experienced nurses. If the number of experienced nurses is less in the ward, the mode of restrictions or restrictive practices deviates. In most cases, patients are gone through highly restrictive conditions as the nurses are less efficient and less experienced to tackle vulnerable patients. 

The negative sides of restrictive strategies

There are various negative effects of restrictive practices which are implemented on the patients that directly affect their basic human rights. From the individual interview of 13 participants, some negative restrictive practices are obtained that are harmful to the patients. For instance, the restrictive practice of not being permitted to have a cup of tea at a certain time is a type of restrictive practice that is implemented to reduce the risk of getting injured from the hot water (Kesztyüs et al. 2019). There might be some patients who have the potential to attack others or himself/herself with the hot water for the tea but generalizing the same situations for every patient are not appropriate. In many ways, this restrictive practice deprived patients of their basic rights. 

Another negative restrictive practice that affects the basic rights of the patients is retaining the patients from getting fresh air at a certain time. The main reason for this restriction is because of the chance of getting away from the forensic secure units. In the medium secure units, patients are admitted for criminal activities or have any past criminal records. It is highly important for the nurses and workers to retain them in secure units for their recovery. Information from the interview session has revealed that there is a lack of staff in the medium secure units which affects the delivery of the service. For this reason, it is difficult to monitor the activities of every patient efficiently (Markham, 2022). As a consequence, nurses or the higher authorities have decided to restrict their free-roaming to get fresh air as there is a risk of running away from the medium secure care. This might be helpful for the nurses to retain the patients in their medium secure units but for most patients, it is difficult to accept while others restrict them to get fresh air. 

Another negative side of restrictive practice is the use of blanket rules for each and every patient. In the forensic care units, various kinds of patients are present whose level of vulnerability is different. For instance, restrictions on having dinner after 12 o’clock for all patients are unnecessary as they are not equally vulnerable. To implement this rule, initially, the level of vulnerability needs to be assessed and the blanket rule needs to be implemented for those highly vulnerable patients. Implementing this rule for every patient is irrelevant although the caregivers imply this for their ease of work.

Harmful effects

Healthcare expenses can rise as a result of restrictive practices. At the point when there is a set number of suppliers or contest is limited, it can prompt monopolistic circumstances where medical care administrations are evaluated higher than they would be in a more cutthroat climate. These increased costs may fall on patients’ shoulders in the form of higher insurance premiums or out-of-pocket expenses (Vizcaya-Moreno, and Pérez-Cañaveras, 2019). Innovation and the adoption of new medical technologies and methods can be hampered by restrictive practices. At the point when guidelines or expert rules unnecessarily limit medical services suppliers, it might deter trial and error and the acquaintance of novel methodologies with finding, therapy, and care. As a result, patients may not have access to cutting-edge treatments and progress may be slowed. Prohibitive practices can fuel existing medical services incongruities. It can widen the gap between different groups of patients if certain populations, like those in rural or underserved areas, face barriers to accessing healthcare as a result of restrictive regulations. Health inequalities, worse outcomes, and unequal access to care are all possible outcomes of this.

Any tactics or limitations applied in a healthcare context that restrict a nurse's access to resources or ability to deliver care are considered restrictive measures. This could be anything from the length of the patient's stay, the amount of staff needed, or the distribution of resources. Although these actions are often taken to better control healthcare costs or maximize resources, they may have negative effects on nurses. First, limiting policies may foster a culture of limitation, which may lower nurses' job satisfaction. Nurses may feel helpless and that their opinions are not valued at work when conditions create it challenging for them to perform their responsibility (Parker et al. 2020). The restrictive practices in the impactful significant preventing the patients maximize the harmful effects and the qualities of the nurse’s aspect. 

• Dignity and autonomy: Restrictive practices can encroach upon patients' dignity and autonomy, potentially leading to a deficiency of confidence and decreased satisfaction with their care.
• Psychological impact: Patients exposed to restrictive measures may encounter increased sensations of anxiety, fear, and isolation, which can further deteriorate their mental prosperity.
• Physical harm: Ill-advised or over-the-top use of restrictive practices can bring about physical wounds, like injuries, fractures, or tension ulcers, compromising patient safety and prosperity.
• Ethical considerations: Carrying out restrictive measures raises ethical dilemmas regarding the balance between patient privileges, autonomy, and the obligation of care.

As a consequence, the quality of the care delivered to patients may suffer. This may decrease their drive to perform their duties to the best of their abilities. Second, restricting measures may cause nurses to experience greater degrees of burnout. Nurses' productivity may suffer as a result of their tiredness from attempting to operate within these restrictions' constraints. Stress-related disorders like depression and anxiety are exacerbated by stressful jobs, which is a further problem (Romero et al. 2020). The climate created by restrictive measures may also be unfavorable to nurses' ongoing professional development. Nurses are constrained in their capacity to advance high-quality patient-centered care when they lack access to the resources they require to advance their knowledge and abilities. 

Critical reflection

This research helps me to find out a wide range of information on restrictive practices. The overall effectiveness of the restrictive practices is significant in the forensic secure units but there are huge gaps between the nurses and MDTs or higher authorities, nurses and patients, and nurses and patients’ relatives and social workers. Hence, I can depict that nurses are the major factors and victims of any disturbance or nuisances in the forensic secure units and they are also the center of attraction. Nurses’ activities operate patients in the forensic care units. Nurses have the capability to modify restrictive practices according to patients’ well-being because higher authorities poorly intervene in their work. After collecting and evaluating a sufficient amount of information, I understand the fact that restrictive practices have some negative sides for which various disturbances are developed. In order to reduce such disturbances, nurses step ahead sometimes and modify such practices for patients’ improvement purposes. As there are fewer interventions of higher authorities or MDTs in the ward, it is easier to implement such modified practices that provide benefits to both patients and nurses. Additionally, nurses experience various adverse situations that increase their practical knowledge, which also helps them to work smoothly without any interruption. In addition to that, nurses are efficient in building a healthy relationship with their patients which eventually reduces the risk of disturbance from their relatives and social workers. While implementing restrictive practices, nurses focus on the psychological changes of patients which is also an effective strategy to improve their working activity within the ward.

6.6 Model and approaches

Telehealth and telemedicine: Utilizing telemedicine and telehealth advancements can assist with conquering geological obstructions and increment admittance to mind, especially in remote or underserved regions. Patients can get to medical care benefits advantageously and diminish the requirement for in-person visits by empowering distant conferences, remote checking, and virtual consideration conveyance.

Enhanced Care Coordination and Collaboration: Empowering joint effort and care coordination among medical services suppliers can work on understanding results and diminish shortcomings (Baker, and Clark, 2019). Improved coordination and efficiency in care can result from improved communication, information sharing, and decision-making through team-based approaches to interprofessional collaboration.

Administrative Changes: To identify and eliminate unnecessary restrictions that hinder innovation and hinder access to care, governments and regulatory bodies can review and revise existing regulations. Streamlining licensing procedures, easing administrative burdens, and encouraging flexibility in healthcare delivery models could all be part of this.

Reducing restrictive practices such as restraints and isolation is essential to providing psychological health services in a certain safe place for all customers, associations, and healthcare workers. Restraints and isolation should be applied only when all less restrictive benefits have been studied and determined to be inappropriate to protect the health along with the safety of all communities accessing mental health convocation (Kesztyüs et al. 2019). There is evidence that restrictive accord can re-traumatize communities that have had past traumatic confessions and deter the advancement of believing deals between caregivers and physicians. 

• Person-centered care: Moving the concentration to individualized care plans and shared decision-making can assist with diminishing the requirement for restrictive practices (Lee and Carlberg, 2020). Engaging patients in care conversations and considering their inclinations can advance a feeling of responsibility and cooperation.
• De-escalation techniques: Training healthcare providers in de-escalation strategies and communication abilities furnishes them with the tools to defuse potentially volatile situations without turning to restrictive measures.
• Multidisciplinary collaboration: Advancing collaboration among healthcare professionals, including nurses, psychiatrists, clinicians, and social laborers, can encourage a far reaching approach to managing challenging behaviors, incorporating different viewpoints and mastery.
• Environmental modifications: Creating a safe and therapeutic environment through physical modifications, for example, limiting mess, giving clear signage, and utilizing calming tones, can add to decreasing the requirement for restrictive measures.
• Education and awareness: Consistent education programs for healthcare professionals on alternative approaches and evidence-based practices can enhance their insight and abilities, encouraging the exploration of non-restrictive intercessions.
• Monitoring and audit frameworks: Carrying out hearty frameworks for monitoring and surveying the use of restrictive practices can assist with identifying patterns, evaluating viability, and driving quality improvement initiatives.

6.7 Conclusion

This chapter represents a broad discussion of the findings of the interview conducted with the nurses and focused group. The evaluation of the interview has revealed various factors that need to be focused on while performing restrictive practices. The most important factor is the maintenance of the integrity of workers which can make the system effective. Furthermore, patients’ bad habits need to be changed for the sake of their health. In this case, proper monitoring, guidance, and community leave can play a crucial role in the restrictive nursing practice. There are various kinds of pressure on nurses which are discussed in this chapter and it is clear that the support from senior staff is poor which causes several problems for the nurses. Furthermore, modern nurses perform evidence-based practice to increase their efficiency in this forensic secure setting. This evidence-based practice helps to manage the patients in the wards and also provides multiple solutions to deal with any kind of adverse conditions in the wards. 

In the following chapter, the research sum up the exploration and make suggestions. RMNs contributions are considered most useful and helpful for this research. The findings revealed that experienced participants briefly elaborated on each of the questions to clear their understanding while inexperienced participants just support those facts or provide some of their arguments during group interviews. On reflection, self-knowledge and self-understanding have been explained which is the outcome of the evaluation of the respondents’ information.

Reference lists

Books

Selekman, J., Shannon, R.A. and Yonkaitis, C.F., 2019. School nursing: A comprehensive text. FA Davis.

Swan, D., O'Brien, D.P., Maunder, W.P.J. and Howe, S., 2018. Competition in British industry: Restrictive practices legislation in theory and practice. Routledge.

Journals

Antón-Solanas, I., Huércanos-Esparza, I., Hamam-Alcober, N., Vanceulebroeck, V., Dehaes, S., Kalkan, I., Kömürcü, N., Coelho, M., Coelho, T., Casa-Nova, A. and Cordeiro, R., 2021. Nursing lecturers’ perception and experience of teaching cultural competence: a European qualitative study. International journal of environmental research and public health, 18(3), p.1357.

Baker, E. and Clark, L.L., 2020. Biopsychopharmacosocial approach to assess impact of social distancing and isolation on mental health in older adults. British journal of community nursing, 25(5), pp.231-238.

Barr, L., Wynaden, D. and Heslop, K., 2019. Promoting positive and safe care in forensic mental health inpatient settings: Evaluating critical factors that assist nurses to reduce the use of restrictive practices. International Journal of Mental Health Nursing, 28(4), pp.888-898.

Bennett, A. and Hanna, P., 2021. Exploring the experiences of male forensic inpatients’ relationships with staff within low, medium and high security mental health settings. Issues in Mental Health Nursing, 42(10), pp.929-941.

Bifarin, O., Felton, A. and Prince, Z., 2022. Defensive practices in mental health nursing: Professionalism and poignant tensions. International Journal of Mental Health Nursing, 31(3), pp.743-751.

Blackwood, D.H., Walker, D., Mythen, M.G., Taylor, R.M. and Vindrola?Padros, C., 2019. Barriers to advance care planning with patients as perceived by nurses and other healthcare professionals: a systematic review. Journal of clinical nursing, 28(23-24), pp.4276-4297.

Chitty, E.G., 2020. Trauma, attachment and inpatient perceptions of restrictive practice in forensic mental health services (Doctoral dissertation, University of Surrey).

Collins, J., Barnoux, M. and Baker, P., 2021. Managing challenging behaviour using applied behavioural analysis and positive behavioural support in forensic settings: A systematic review. International Journal of Positive Behavioural Support, 11(1), pp.15-41.

Cooley, R., 2019. Experiences of restrictive practices in inpatient psychiatric services: Staff and patient perspectives (Doctoral dissertation, University of Warwick).

Doyle, A. and Clark, L.L., 2020. How ward rules and limit setting contribute towards restrictive practices and presentations of challenging behaviour in patients on mental health wards. British Journal of Mental Health Nursing, 9(2), pp.1-9.

Flammer, E., Frank, U. and Steinert, T., 2020. Freedom restrictive coercive measures in forensic psychiatry. Frontiers in psychiatry, 11, p.146.

Fletcher, J., Hamilton, B., Kinner, S.A. and Brophy, L., 2019. Safewards impact in inpatient mental health units in Victoria, Australia: Staff perspectives. Frontiers in Psychiatry, p.462.

Goodman, H., Papastavrou Brooks, C., Price, O. and Barley, E.A., 2020. Barriers and facilitators to the effective de-escalation of conflict behaviours in forensic high-secure settings: a qualitative study. International journal of mental health systems, 14(1), pp.1-16.

Government of the UK, 2021. Available at: https://www.gov.uk/government/publications/leave-guidance [Accessed on: 18.03.23]

Government of the UK, 2023. Available at: https://www.legislation.gov.uk/ukpga/1983/20/contents [Accessed on: 18.03.23]

Gray, T.A., Wilson, P., Dumville, J.C. and Cullum, N.A., 2019. What factors influence community wound care in the UK? A focus group study using the Theoretical Domains Framework. BMJ open, 9(7), p.e024859.

Haines-Delmont, A., Tsang, A., Szifris, K., Craig, E., Chapman, M., Baker, J., Baker, P., Ridley, J., Thomson, M., Bourlet, G. and Morrison, B., 2022. Approaches used to prevent and reduce the use of restrictive practices on adults with learning disabilities: Protocol for a realist review. Plos one, 17(9), p.e0270028.

Hansen, A., Hazelton, M., Rosina, R. and Inder, K., 2020. Factors associated with seclusion use in forensic mental health settings: an integrative review. International Journal of Forensic Mental Health, 19(2), pp.198-213.

Hawkins, S.S. and Hacker, M.R., 2022. Trends in use of conventional cigarettes, e-cigarettes, and marijuana in pregnancy and impact of health policy. Clinical Obstetrics and Gynecology, 65(2), pp.305-318.

Hayward, B.A., McKay-Brown, L. and Poed, S., 2023. Restrictive practices and the ‘need’for Positive Behaviour Support (PBS): A critical discourse examination of disability policy beliefs. Journal of Intellectual Disabilities, 27(1), pp.170-189.

Heise, L., Greene, M.E., Opper, N., Stavropoulou, M., Harper, C., Nascimento, M., Zewdie, D., Darmstadt, G.L., Greene, M.E., Hawkes, S. and Henry, S., 2019. Gender inequality and restrictive gender norms: framing the challenges to health. The Lancet, 393(10189), pp.2440-2454.

Hext, G., Clark, L.L. and Xyrichis, A., 2018. Reducing restrictive practice in adult services: not only an issue for mental health professionals. British Journal of Nursing, 27(9), pp.479-485.

Jolly, S., 2022. Teamwork and decision-making in forensic inpatient settings in Scotland (Doctoral dissertation, University of Glasgow).

Kalkan U?urlu, Y., Matarac? De?irmenci, D., Durgun, H. and Gök U?ur, H., 2021. The examination of the relationship between nursing students' depression, anxiety and stress levels and restrictive, emotional, and external eating behaviors in COVID?19 social isolation process. Perspectives in Psychiatric Care, 57(2), pp.507-516.

Kennedy, H.G., Mullaney, R., McKenna, P., Thompson, J., Timmons, D., Gill, P., O’Sullivan, O.P., Braham, P., Duffy, D., Kearns, A. and Linehan, S., 2020. A tool to evaluate proportionality and necessity in the use of restrictive practices in forensic mental health settings: the DRILL tool (Dundrum restriction, intrusion and liberty ladders). BMC psychiatry, 20(1), pp.1-20.

Kesztyüs, D., Cermak, P., Gulich, M. and Kesztyüs, T., 2019. Adherence to time-restricted feeding and impact on abdominal obesity in primary care patients: Results of a pilot study in a pre–post design. Nutrients, 11(12), p.2854.

Kesztyüs, D., Cermak, P., Gulich, M. and Kesztyüs, T., 2019. Adherence to time-restricted feeding and impact on abdominal obesity in primary care patients: Results of a pilot study in a pre–post design. Nutrients, 11(12), p.2854.

Kriakous, S.A., Elliott, K.A. and Owen, R., 2019. Coping, mindfulness, stress, and burnout among forensic health care professionals. Journal of Forensic Psychology Research and Practice, 19(2), pp.128-146.

Lawrence, D., Bagshaw, R., Stubbings, D. and Watt, A., 2022. Restrictive practices in adult secure mental health services: A scoping review. International Journal of Forensic Mental Health, 21(1), pp.68-88.

Lean, K. and Sims, N., 2022. Restrictive Practice.

Lee, K. and Carlberg, K.T., 2020. Model reduction of dynamical systems on nonlinear manifolds using deep convolutional autoencoders. Journal of Computational Physics, 404, p.108973.

Levy, J.K., Darmstadt, G.L., Ashby, C., Quandt, M., Halsey, E., Nagar, A. and Greene, M.E., 2020. Characteristics of successful programmes targeting gender inequality and restrictive gender norms for the health and wellbeing of children, adolescents, and young adults: a systematic review. The Lancet Global Health, 8(2), pp.e225-e236.

Liddell, K., Keene, A.R., Holland, A., Huppert, J., Underwood, B.R., Clark, O. and Barclay, S.I., 2021. Isolating residents including wandering residents in care and group homes: Medical ethics and English law in the context of Covid-19. International journal of law and psychiatry, 74, p.101649.

Lincolnshire Partnership Foundation Trust, 2020, Acute Inpatient Wards. Available at: https://www.lpft.nhs.uk/our-services/adults/acute-inpatient-wards#:~:text=Acute%20care%20deals%20with%20people,with%20by%20a%20community%20service. [Accessed on: 18.03.23]

Maguire, T., Ryan, J. and McKenna, B., 2021. Benchmarking to reduce restrictive practices in forensic mental health services: a Delphi study. Australasian Psychiatry, 29(4), pp.384-388.

Maguire, T., Ryan, J., Fullam, R. and McKenna, B., 2022. Safewards Secure: A Delphi study to develop an addition to the Safewards model for forensic mental health services. Journal of Psychiatric and Mental Health Nursing, 29(3), pp.418-429.

Markham, S., 2022. See think act: the need to rethink and refocus on relational security. The Journal of Forensic Psychiatry & Psychology, 33(2), pp.200-230.

Markham, S., 2022. Totalitarian approaches to risk and the banality of harm in secure and forensic psychiatric settings in England and Wales. Ethics, Medicine and Public Health, 23, p.100776.

Markham, S., 2023. The individual as a marginalised cohort in secure and forensic mental health inpatient settings in the United Kingdom. In Diversity and Marginalisation in Forensic Mental Health Care (pp. 151-159). Routledge.

McCullough, S., Stanley, C., Smith, H., Scott, M., Karia, M., Ndubuisi, B., Ross, C.C., Bates, R. and Davoren, M., 2020. Outcome measures of risk and recovery in Broadmoor High Secure Forensic Hospital: stratification of care pathways and moves to medium secure hospitals. BJPsych open, 6(4), p.e74.

McSherry, B. and Maker, Y., 2021. Restrictive practices: Options and opportunities.

Morris, D.J., Webb, E.L., Stewart, I., Galsworthy, J. and Wallang, P., 2021. Comparing co-production approaches to dynamic risk assessments in a forensic intellectual disability population: Outcomes of a clinical pilot. Journal of Intellectual Disabilities and Offending Behaviour, 12(1), pp.23-36.

Mullen, A., Browne, G., Hamilton, B., Skinner, S. and Happell, B., 2022. Safewards: An integrative review of the literature within inpatient and forensic mental health units. International journal of mental health nursing, 31(5), pp.1090-1108.

Oates, J., Topping, A., Ezhova, I., Wadey, E. and Marie Rafferty, A., 2020. An integrative review of nursing staff experiences in high secure forensic mental health settings: Implications for recruitment and retention strategies. Journal of Advanced Nursing, 76(11), pp.2897-2908.

Oates, J., Topping, A., Ezhova, I., Wadey, E. and Rafferty, A.M., 2021. Factors affecting high secure forensic mental health nursing workforce sustainability: Perspectives from frontline nurses and stakeholders. Journal of psychiatric and mental health nursing, 28(6), pp.1041-1051.

Olausson, S., Wijk, H., Johansson Berglund, I., Pihlgren, A. and Danielson, E., 2021. Patients’ experiences of place and space after a relocation to evidence?based designed forensic psychiatric hospitals. International Journal of Mental Health Nursing, 30(5), pp.1210-1220.

Paradis-Gagné, E. and Guimond, V., 2020. Implementation of the mental health nurse practitioner role in forensic settings: A case report. Journal of Forensic Nursing, 16(3), pp.179-182.

Parke, S., Hunn, L., Holland, T., Preston, L., McCarthy, L. and Day, M., 2019. Restrictive interventions: a service evaluation. Mental Health Practice, 22(5).

Parker, M.J., Fraser, C., Abeler-Dörner, L. and Bonsall, D., 2020. Ethics of instantaneous contact tracing using mobile phone apps in the control of the COVID-19 pandemic. Journal of Medical Ethics, 46(7), pp.427-431.

Parraga, G. and Morissette, M.C., 2020. E-cigarettes: what evidence links vaping to acute lung injury and respiratory failure?. Canadian Journal of Respiratory, Critical Care, and Sleep Medicine, 4(1), pp.48-54.

Poghosyan, L., Kueakomoldej, S., Liu, J. and Martsolf, G., 2022. Advanced practice nurse work environments and job satisfaction and intent to leave: Six?state cross sectional and observational study. Journal of Advanced Nursing, 78(8), pp.2460-2471.

Rabab, S., Tomlin, J., Huband, N. and Völlm, B., 2020. Care quality commission inspections of high-security hospitals. The Journal Of Forensic Practice, 22(2), pp.83-96.

Romero, E., López-Romero, L., Domínguez-Álvarez, B., Villar, P. and Gómez-Fraguela, J.A., 2020. Testing the effects of COVID-19 confinement in Spanish children: The role of parents’ distress, emotional problems and specific parenting. International journal of environmental research and public health, 17(19), p.6975.

Rule, A., 2019. Psychiatric intensive care. Oxford Textbook of Inpatient Psychiatry, p.305.

Sashidharan, S.P., Mezzina, R. and Puras, D., 2019. Reducing coercion in mental healthcare. Epidemiology and psychiatric sciences, 28(6), pp.605-612.

Sizoo, E.M., Monnier, A.A., Bloemen, M., Hertogh, C.M. and Smalbrugge, M., 2020. Dilemmas with restrictive visiting policies in Dutch nursing homes during the COVID-19 pandemic: a qualitative analysis of an open-ended questionnaire with elderly care physicians. Journal of the American Medical Directors Association, 21(12), pp.1774-1781.

Stevenson, C. and Taylor, J., 2020. Nurses' perspectives of factors that influence therapeutic relationships in secure inpatient forensic hospitals. Journal of Forensic Nursing, 16(3), pp.169-178.

Sustere, E. and Tarpey, E., 2019. Least restrictive practice: its role in patient independence and recovery. The Journal of Forensic Psychiatry & Psychology, 30(4), pp.614-629.

Thomas, J.J., Becker, K.R., Kuhnle, M.C., Jo, J.H., Harshman, S.G., Wons, O.B., Keshishian, A.C., Hauser, K., Breithaupt, L., Liebman, R.E. and Misra, M., 2020. Cognitive?behavioral therapy for avoidant/restrictive food intake disorder: Feasibility, acceptability, and proof?of?concept for children and adolescents. International Journal of Eating Disorders, 53(10), pp.1636-1646.

Tomlin, J., 2020. What does social distancing mean for patients in forensic mental health settings?. Forensic Science international. Mind and law, 1, p.100018.

Tomlin, J., Egan, V., Bartlett, P. and Völlm, B., 2020. What do patients find restrictive about forensic mental health services? A qualitative study. International Journal of Forensic Mental Health, 19(1), pp.44-56.

Tu, S. and Recht, B., 2019, June. The gap between model-based and model-free methods on the linear quadratic regulator: An asymptotic viewpoint. In Conference on Learning Theory (pp. 3036-3083). PMLR.

Tully, S.M., Bucci, S. and Berry, K., 2023. “My life isn't my life, it's the systems”: A qualitative exploration of women's experiences of day?to?day restrictive practices as inpatients. Journal of Psychiatric and Mental Health Nursing, 30(1), pp.110-122.

Vizcaya-Moreno, M.F. and Pérez-Cañaveras, R.M., 2020. Social media used and teaching methods preferred by generation z students in the nursing clinical learning environment: A cross-sectional research study. International journal of environmental research and public health, 17(21), p.8267.

Von Bogdandy, A. and Villarreal, P., 2020. International law on pandemic response: a first stocktaking in light of the coronavirus crisis. Max Planck Institute for Comparative Public Law & International Law (MPIL) Research Paper, (2020-07).

Watson, T.M. and Choo, L., 2021. Understanding and reducing unauthorized leaves of absence from forensic mental health settings: A literature review. The Journal of Forensic Psychiatry & Psychology, 32(2), pp.181-197.

Webb, E.L., Ireland, J.L., Lewis, M. and Morris, D., 2023. Potential sources of moral injury for healthcare workers in forensic and psychiatric settings: A systematic review and meta-ethnography. Trauma, Violence and Abuse.

Websites

Wilson, R.L., Hutton, A. and Foureur, M., 2023. Promoting mental health recovery by design: Physical, procedural, and relational security in the context of the mental health built environment. International Journal of Mental Health Nursing, 32(1), pp.147-161.

Chapter 7: Conclusion

7.1 Introduction

Restrictive practices can be of various types. Widely used restrictive practices in all types of medium secure units and high dependency units are the seclusion practices and strict maintenance of a particular schedule. The seclusion process is categorized into two different categories such as locked-door seclusion and open-door seclusion. The locked-door seclusion is mostly used for a group of particular patients who possess a high risk to other patients or staff. In this approach, patients are locked in a room and under constant observation. During this time, all the activities of the patients are confined to their allocated rooms in a locked environment. This approach reduces the chance of injury to other patients and staff. Furthermore, patients can be self-harming in nature, which can create a high chance of doing damage to themselves during locked-door seclusion. To reduce this threat, the room where patients are enclosed contains not a single item that can cause self-damage to them (Parker et al. 2022). Furthermore, they are kept under constant observation which also reduces the level of threat. In the case of open-door seclusion, the patients who are in an improved condition in locked-door seclusion and the patients who possess a slight threat to others are kept in the room. In this case, the people are kept in an unlocked room where the nurses interact with them in 1:1 conversation. This type of seclusion approach is very much less restrictive than that of locked-door seclusion and the patient can communicate with other patients.

In some cases, the restrictive practices cause serious violations of basic human rights which is justified by the nurse as the practices are for the betterment of the patients admitted to the care. The restrictive practices are somewhat dominative in nature which dominates the patients ' activities inside the ward to improve their mental health and behavior. In the medium secure units, patients often feel that their basic rights are violated but there is no way to protest as there is no one to hear. Sometimes the family members of the patient or the human rights activists cause serious trouble to the workers of the medium secure units as they have less knowledge of the process of caring for this type of patient.

The violation of basic human rights is performed due to the implementation of restrictive practices on patients ' consumption of food along with their drinking behavior. In the medium secure units, the foods are provided for a particular time during which patients need to collect their food and consume it. Any patient who fails to collect food and consume it during this time is not provided with the food later. This causes a violation of human rights as any person has the right to have food at their desirable time (Wood et al. 2021). Furthermore, in the medium secure units, there are restrictions on having a cup of tea at unusual times. The nurses justified this restriction as this can help patients to get a good sleep at night and also reduce the risk of performing any damage to others using the hot water for the tea. There are some other restricted practices that affect patients ' lives. One such practice is the restriction on roaming freely inside the ward or in the garden within the facility. The nurses perform this restrictive practice to compensate for the shortage of sufficient staff in those units.

In the medium care units, patients often face difficulties while asking for leaves. As the patients admitted in the medium secure units have a criminal history, they are a high threat to society and they are constantly monitored for their activities. In such conditions, if they are allowed to take leave there will be a high chance of not returning further to the medium secure units or those patients ' conditions might be degraded due to improper activities outside of the ward. Furthermore, they can be involved in bad habits from which they are retained till the time before leaving. Patients in the medium secure units may have some chronic diseases for which there are some restrictions on their behavior (Sustere, and Tarpey, 2019). People are often involved in bad habits like the consumption of unhealthy foods, smoking, consumption of alcohol, etc. These bad and unhealthy behaviors are banned inside the medium secure units but outside the medium secure units, there is no one to monitor them which increases the chance of being involved in unhealthy habits.

In the forensic secure units, there are multiple restrictive practices that are often performed by the nurses in order to maintain a healthy life for the patients. In most cases, these practices are controlled by the higher authorities or MDT, and the nurses are bound to perform their duties whether it is good for patients or not (Leif et al. 2023). MDT mostly establishes the rules based on the suggestion of psychiatrists but never takes or listens to any opinions from the nurses who have practical knowledge and experience in patient handling. Some of the rules established by the MDT often cause disturbance and dissatisfaction among the patients along with the nurses. In this case, nurses need to solve the issue with their experience or evidence-based knowledge. In some cases, nurses are forced to imply the rules made by MDT without any modifications.

There is also a clash between the experienced nurses and the newly appointed nurses because of their difference in training. In the case of experienced or old nurses, they are more focused on on-field experience instead of bookish knowledge as they believe that practical experience can reduce the number of problems created in the medium secure units (Perruchoud et al. 2021). On the other hand, nurses who are newly joined in the medium secure units are mostly trained in evidence-based approaches. This makes those nurses dependable on evidence-based studies for every situation. This also results in solving any situation by those nurses without having any practical experience, instead, they can solve the issue simply with the assistance of an evidence-based approach. There is a fine boundary between old and experienced nurses and newly trained nurses and it is also clear that in most cases, new nurses efficiently handle the situations and they do not need the assistance of experienced nurses (Al-Busaidi et al. 2019). On the contrary, there are some situations that cannot be solved only with the help of an evidence-based approach, instead, practical experience is also necessary to handle those situations. In those cases, experienced nurses perform their job efficiently.

7.2 Discussion on key big issues

In this dissertation, individual interviews with 13 nurses and group discussions with 6 focused participants are performed. The nurses have explained their thoughts and perceptions regarding restrictive practices in the medium secure units. In the medium secure units, they face multiple problems during their work duration. At their work premises, sometimes they are forced to imply restrictive practices by higher authority, and sometimes they imply those on their own (Magnusson et al. 2020). They have explained the characters of patients inside the medium secure units and the way they behave with each other. While working in medium secure units, nurses are highly prone to get injured by any of the patients although they handle their patients efficiently. Strategies for tackling patients are different for each nurse. As the nurses are in contact with patients for a long time, they are chosen as the sample/participants of the interview process. In many cases, it has been seen that nurses fail to perform their jobs efficiently as they cannot take the necessary decisions because of poor decision-making skills. In this case, experienced nurses help them to perform their job duty effectively by providing proper decisions regarding the situation. Furthermore, all the patients are monitored by nurses inside the medium secure units. Their role in these secure units is significant. The nurses also tackle patients ' families and human rights activists in an efficient manner (Griffith et al. 2021). They have a wider knowledge about their work such as the knowledge of various restrictive practices, the rules and regulations related to mental health, basic human rights, and the negative effect of the restrictive practices on a patient for a long time. This knowledge helps them to maintain the balance of restrictive practices inside the medium secure units.

There is growing concern about the harmful physical and psychological effects of restrictive behavior. Recent qualitative studies suggest that coercion can cause high levels of stress, anxiety along with anxiety in both patients and staff. Coercion and isolation can also element relapses of trauma in those ‘who accept accomplished environmental or sexual corruption '. A systematic review found “post-traumatic stress disorder (PTSD)” rates of 25-47% in post-restraint psychiatric hospitalizations, demonstrating adverse psychological effects (Both-Nwabuwe et al. 2020). Not surprisingly, considering the detrimental psychological effects of restrictive behavior, restrictive behavior has been shown to impede patient recovery and prolong hospital stays. Similarly, the overwhelming majority of employees who recycled restrictive methods reported negative psychological importance, including feelings of guilt, self-doubt, and job failure. Both groups acknowledge a certain the adoption of restrictive practices affects staff-patient relationships. Although qualitative studies investigating patient and staff life of restrictive practices are well established, a systematic review of previously mentioned evidence is still lacking (Fisher and Kiernan, 2019). Therefore, the aim of this study was to investigate the experiences of patients and staff providing restrictive care in an inpatient acute psychiatric unit. To accept the eccentricity of experiences between groups and to enable the individual study and comparison of patient and staff experiences in restrictive practices in order to make important recommendations.

Patients reported that the quality of employee communication determined whether the situation escalated to restraint. It also states that the quality of ‘communication is fundamental to understanding the reasons for a hold or withdrawal '. Patients found that lack of staff communication skills was one of the most common reasons for their behavior to escalate to the point of reluctance. For example, participants described staff as being unresponsive, not actively listening, and failing to articulate the expectations of patients (Hossain et al. 2021). Patients felt that staff were abusing their authority by engaging in restrictive behavior too early, leading to a "them versus us" ward culture. Some patients ‘recalled situations of bondage ' in which they felt staff were laughing at them, leading to the impression that staff was mocking and ultimately antagonizing them.

7.3 Linking with Objectives

Current rules governing RMNs, carers, relatives, and patients in the restrictive practices

Currently, there are multiple rules regarding restrictive practices associated with the RMNs, carers, relatives, and patients. For the RMNs and carers, the application of restrictive practices must be based on the ongoing situation and condition of the patient. They must follow the rules regarding restrictive practices as set by MDTs. They are not bound to raise any voice against any rules whether those are beneficial for patients or not. RMNs should imply their knowledge, experience, and evidence-based practice approach to handle any adverse situation that arises inside the ward, and if in that case, they require to apply restrictive practices, they are allowed to do so (Griffiths et al. 2022). They must monitor all the activities of the patients inside the ward and should plan for individual care according to their behavior. In fact, caregivers need to be more conscious about the activities of patients to ensure the maintenance of safety inside the ward. Numerous restrictive practices are only performed for their ease of the work irrespective of the fact that patients might face problems following such rules. These rules might hurt the basic human rights of patients but they are often forced to follow these properly.

The relatives of the patients are highly concerned about them. They often raise questions when their patients do not get any leave after application. Relatives do not understand the reason behind the non-approval of leave, instead, they protest against such behaviors. In many cases, it has been seen that relatives take help of the human rights activists to create disturbance inside the medium secure units. The behavior of the relatives exhibits that they usually do not concern about the health condition of their patients rather they put more focus on whether their patients are getting leaves or not. When they take the assistance of human rights activists, they fight for the proper rights of patients. They describe the violation of human rights inside the forensic secure units but do not want to know the reason behind the violation. It is often seen that patients or human rights activists are less knowledgeable about the working behavior of the nurses inside the medium secure units along with the types of patients admitted inside there (Stajduhar et al. 2020). Due to less knowledge, they are fighting for maintaining human rights properly although some of those are harmful to patients as those can reduce the recovery rate of their mental health conditions. Furthermore, the relatives are unaware of the fact that their patients can involve in multiple bad habits which are restricted inside the ward or they can run away from the ward forever once they get leave from the ward. There are no such dedicated rules for the relatives of patients although there are several restrictive practices that are performed on patients which indirectly reduce the influence of the relatives on the ward activities.

Patients are the most important stakeholder upon which multiple rules are governed. They are the center of all stakeholders and their activities. Patients inside the medium secure unit are restricted in multiple ways as they come to the ward due to criminal activities. There are various restrictive rules implied upon patients to control their behavior, various activities, and social connections. Firstly, patients are restricted to have food on their own time (Stajduhar et al. 2020). There are certain times when patients have to consume their breakfast, lunch, or dinner. Failure to consume food during that time can result in the unavailability of food for them. There are some restrictive practices that control the drinking behavior of patients because drinking tea at an unusual time might not be dangerous but there is a possibility that a patient can harm himself or other patients with the hot water provided for tea (Stevenson, and Taylor, 2020). For such reason, the restrictions on drinking behavior have been implied. To reduce the connection between patients and their relatives, there is a restriction on using mobile phones at certain times. This effectively reduces the unnecessary disturbance of relatives. There are some instances, where nurses and carers have implied some restrictions for their own convenience. One such restrictive practice is the restriction on wandering around the ward at patients ' own will. There are certain times when patients wander around the ward or in the garden. These restrictive practices are performed to compensate for the scarcity of sufficient staff who can constantly monitor patients ' activities when they are wandering as there is a risk of escaping.

In the healthcare settings this type of intervention is used to manage and control the behavior of patients who pose a risk to themselves or others are referred to as restrictive practices. These practices are executed when less prohibitive measures have been considered deficient. Restrictive practices should conform to nearby regulations, guidelines, and moral principles. The rationale, considered alternatives, and ongoing evaluation of the intervention are all essential components of the documentation needed to support the use of restrictive practices. Medical services suppliers need to constantly look for the most un-prohibitive choice to oversee testing ways of behaving (Savarimuthu, 2020). Before resorting to physical restraints or isolation, this entails investigating alternative interventions like demobilization techniques, communication strategies, or changes to the environment. Rules for restrictive practices for relatives are also the same according to nurses ' perspectives.

7.4 Knowledge of study

Patients and their loved ones ought to be made aware of the potential use of restrictive practices, the motives behind them, and the outcomes that could result from them. Medical services suppliers need to keep up with open lines of correspondence, including patients and their encouraging groups of people to taking of decisions whenever the situation allows. Healthcare providers should have to provide specialized training to implement restrictive practices according to current rules governing the restrictive practices in different sections (Leif et al. 2023). This section of the treatment of relative practices should be focused on preventing conflicts. To provide fair treatment this type of restrictive practice is very necessary. For all the patients who are admitted to the hospital. They should provide transparency and impartiality in treatment than the other patients. All patients should have to provide equal rights in treatment. Nepotism should have to be prohibited.

All patients should have to be equally treated. The participation of relatives in the appointment or decision-making processes is frequently restricted by regulations in government and public service. By avoiding situations in which individuals may use their positions of power to benefit their close relatives, these measures aim to prevent conflicts of interest and maintain public trust. order To guarantee that the tenets of fairness and accountability are upheld, these regulations may be applicable to positions that include civil servants and high-ranking officials. The rule governing relatives may pertain to the recusal of judges or lawyers from cases involving their close relatives in legal and judicial contexts (Solberg et al. 2023). This is to keep away from any apparent predisposition or unjustifiable benefit that could emerge from individual connections, guaranteeing a fair and unbiased legitimate interaction. The rule governing relatives may pertain to the recusal of judges or lawyers from cases involving their close relatives in legal and judicial contexts.

This is to keep away from any apparent predisposition or unjustifiable benefit that could emerge from individual connections, guaranteeing a fair and unbiased legitimate interaction. The offices need to endeavor to persistently further develop their works on in regards to the administration of testing ways of behaving (Durkin et al. 2019). This entails actively investigating and putting into practice alternative strategies, as well as assessing the efficacy of restrictive interventions and soliciting feedback from staff members and patients.

Determination of working and non-working rules for patients and staff

In medium secure units, there are various rules and regulations for patients and staff. These rules help to maintain discipline inside the ward. The rules which are implied to patients and staff as well are determined by the higher authorities of the forensic secure units or the MDTs of those units. They determine which rule should be working and which one is non-working for the stakeholders. There are various working rules which are implied to stakeholders on a daily basis. For example, the rule of free-roaming inside the ward and in the garden at any time of the day. Patients are not allowed to do so as they have criminal histories and unstable mental conditions (Massey, 2021). This rule is applied to those wards where the number of staff is insufficient and there is difficulty in monitoring all patients at the same time by the available staff. Due to unstable mental health conditions and criminal backgrounds, these patients cannot be kept out of carers ' sight which facilitates the introduction and active implication of this rule.

Another working rule is the restriction on using mobile phones unnecessarily at any time. There are multiple instances where relatives of patients or human rights activists cause disturbance to the carers and nurses of medium secure units on the ground of violation of basic human rights. Mobile phone helps to communicate with anyone outside the ward without any difficulty, which can bring any type of problematic situation to the medium secure units. To reduce this type of circumstance, the restriction on using mobile phones for a long time or at any time is implied although there are certain times when patients can use mobile phones to communicate with their families or relatives under the supervision of carers (Lawrence et al. 2022). This working rule effectively reduces the unpredictable disturbance of relatives and human rights activists in the ward.

There is a working rule regarding the consumption of food and drinking tea. Patients inside the medium secure units are supposed to eat their food at a particular time to maintain a disciplined schedule. This rule is a violation of human basic rights but it is implied to patients forcibly by the higher authorities. Moreover, patients who do not follow this rule may be punished with other activities such as not giving the chance of shopping on their own choice. This is a non-working rule which is implied to follow the working rule. This non-working rule is different in various wards and it is not the major rule without which the restrictive practices are of no use. There is another punishment for disobeying the working rule which is not providing food for that particular period to those patients. Patients are also restricted by the rule of having tea for drinking at a particular time. This rule ensures the safety of the other patients inside the ward as anyone can be harmed or injured by the hot water provided for tea (Leif et al. 2023). This rule deprived many patients of having tea on their own time. There is a positive side to this rule i.e. restricting drinking tea during the night improves patients ' sleeping activities that result in the improvement of patient 's health.

There are some rules for the nursing staff who work in medium secure units. Nurses are the major stakeholder who constantly gets in touch with patients of medium secure units which increase the necessity of certain rules that can improve the activities of nurses. Firstly, nurses must follow the rules set by MDTs or higher authorities without asking any questions (Duxbury et al. 2019). The restrictive rules made for patients are often harmful to them due to which nurses as their carers raise many questions and requests to change certain rules. This rule has been implied to nurses to avoid such situations further and force them to do such practices. Secondly, nurses have to do some activities which violate human rights law or the laws associated with mental health. Depending on some adverse situations, nurses need to decide the course of action and imply it immediately (Markham, 2022). There are some other rules where each group of nurses consists of at least one experienced nurse who has the capability of handling any situation. There are some relaxations where nurses can perform activities suitable for a particular situation. They can imply their knowledge from experience or their evidence-based knowledge to handle any adverse situation. All these rules for different stakeholders help to maintain discipline inside the medium secure units and to reduce unavoidable circumstances.

For evidence-based human rights situations with basic rules and guidelines. The law also is logical for the “Mental Health Commission” to develop rules for the application of confinement and isolation in licensed centers. He has published two adaptations of these rules, the last of which came into force in 2010. The regulations specify procedures for the use of isolation and mechanical restraints such as Patient dignity and safety. Opportunity for isolation. recording; CCTV use; employee training; along with clinical governance (Meaklim et al. 2020). Although the above relates mainly to mental health convocation, it is critical to the character that isolation and restraint laws and regulations may also apply to services for the elderly and persons with disabilities. For case, some community has a double diagnosis of having a creative or learning ailment in addition to the diagnosed psychiatric disorder.

The data in this document is for general guidance only. It does not create legal or competent advice and allows it not to be relied upon as a legal account in any administration. The NDIS Quality and Safety Committee makes every acceptable effort to administer modern and careful advice, although does not guarantee the certainty, timeliness, or completeness of this information. This guide was created for registered NDIS Providers and NDIS Behavioral Consultants who support NDIS participants (Charette et al. 2019). However, it is allowed also to be of activity to those who support people with disabilities. This guide supports a modern framework for supporting positive behavior.

To guarantee patient safety, efficiency, and respectful treatment in restrictive healthcare practices, it is essential to establish working rules for staff and patients. The purpose of these regulations is to establish guidelines that strike a balance between the rights and requirements of patients and the duties and capabilities of healthcare workers. Working rules in restrictive practices require open communication of expectations and restrictions for patients. This incorporates illuminating patients about their freedoms, illustrating the limits of their way of behaving, and making sense of the results of resistance (Wolverson et al. 2023). Respect the authority and expertise of healthcare professionals while encouraging patients to actively participate in their treatment plans. To safeguard patients' autonomy and well-being, measures like informed consent, privacy protection, and individualized care plans should be implemented. Staff individuals, then again, need to comply to lay out conventions and moral rules while working with patients in prohibitive practices.

For them to acquire the necessary abilities for efficient management and support, they need to receive the appropriate education and training. Staff should keep a caring and non-critical demeanor towards patients, guaranteeing their poise and security are regarded consistently. Cooperative direction, ordinary correspondence, and a group-based approach are fundamental for staff to cooperate productively and give thorough consideration. To safeguard the privacy and confidential information of those involved in forensic investigations, all staff members are required to uphold strict patient confidentiality (Sacre et al. 2022). Adherence to lawful and moral commitments, for example, the Medical Coverage Compactness and Responsibility Act (HIPAA), is vital. To preserve the integrity of the evidence during investigations, staff members must adhere to established procedures for its handling and preservation.

To avoid contamination or tampering, proper documentation, labeling, and secure storage are essential. All forensic evidence must have a proper chain of custody maintained by staff members. This entails accurately documenting the handling and transfer of evidence to guarantee its admissibility in court. Various departments of forensics must work together and communicate effectively. For precise case evaluation and examinations, there are required pathologists, legal researchers, and different patterns (Goulet et al. 2023). Staff individuals are eager to participate in continuous expert improvement to upgrade their insight and abilities in criminological sciences. Standard instructional courses and studios guarantee that workers stay refreshed with the most recent procedures, headways, and legitimate necessities in their particular fields.

The forensic department should look for ways to improve its operations on a regular basis. Changes to policies, equipment, or workflows can be made based on feedback from patients, staff, and external agencies to improve overall efficiency and effectiveness (Ashley et al. 2022). The functions standards for patients and staff in the measurable division focus on quiet privacy, proof safeguarding, security, joint effort, training, moral direction, quality confirmation, crisis reaction, and consistent improvement. The objective of these guidelines is to guarantee the provision of accurate forensic services while preserving patient and staff safety.

7.5 Modification of rules

Rules made by higher authorities or MDTs must be modified for the purpose of maintaining equilibrium between the activities of patients and nurses. Various types of new problems are arising daily inside the medium secure wards which cannot be managed with a fixed rule. A change or modification in the rules is a significant criterion to manage a ward having patients with unstable mental health and criminal records. As the rules are set by MDTs or the higher authorities, the power to modify the rules is in their hands although they do not modify rules very often. They force nurses to execute and maintain those rules. The modification of these rules is done by the nurses themselves unofficially (Chitty, 2020). As the higher authorities do not intervene inside the ward or look after the ward activities, it is easier for nurses to imply some modified rules to patients which can help to recover them speedily.

There is a rule of not giving food to patients if they fail to collect and consume their food within a specified time. It is difficult for some nurses to see their patients deprived of food. For this reason, they provide some food to those patients without informing superiors. This may affect patients ' discipline but on the contrary, this removes the charges of violation of basic human rights. In addition, there is another rule which is similar to this rule. The rule is the restricted drinking behavior of patients. This rule restricts patients from drinking tea at any time. This rule reduces the risk of injury from hot water although it violates the basic human rights of patients. Nurses of some medium secure units modify some factors which satisfy both the maintenance of the rule and the desire of the patients. Instead of providing hot water for tea, nurses provide lukewarm water for making tea which effectively reduces the risk of getting injured. This modification satisfies the needs of patients (Goodman et al. 2020). Although this disobeys the rule of restrictive drinking behavior set by the higher authorities, it also satisfies the purpose for which the original rule is implemented.

There are some rules regarding the seclusion policy which are also modified by the nurses to ensure the health of patients' mental health. The original rule states that any risky patient must be secluded from other patients and staff. Usually, some patients have high anger issues and possess threats to other patients along with the staff. Such patients must be secluded in a locked-door room where they cannot communicate or get in touch with other stakeholders. Few experienced nurses have modified rules when they are in charge of the ward (Meehan et al. 2022). They do not easily seclude patients in locked-door conditions, rather they put more importance on interacting with those patients in 1:1 conversations where they hear the patient 's issues or problems and solve them as much as they can. Further, they convince the patient and help them to calm down during this 1:1 interaction session. This approach reduces the locked-door seclusion policy in an effective way and also provides a better result when assessing the mental health of the patients.

During the leave of a patient, several factors have been assessed to ensure the safety of society from that patient. There are several instances where patients are not allowed to leave the ward in any condition. In such cases, various problems arise from the patients ' ends To reduce such disturbance, many nurses modify the rule of leaving. If there is any serious or essential purpose for which a patient must leave the ward for a while, a carer must assist them to monitor his activities when he is outside of the ward (Carthy, and Hillier, 2023). There are some other implementations such as using handcuffs for patients who leave the ward for medical purposes. These activities reduce the risk of escaping or harming others.

In a nutshell, it can be said that the modification of rules is for the improvement of patients ' mental health conditions. There are several rules implied to the patients which are harmful to them. These types of rules are modified by some experienced nurses keeping in view that it does not affect the purpose of implementation of such rules (Baker et al. 2021). During the interview, many participants stated that they have no right to change the rules but for the sake of admitted patients, they modify multiple rules that do not harm the purpose of the original rules on one side and fulfill patients ' desires on the other side.

Beneficial restrictive practices for staff

Restrictive practices initiates to restrict the solitary turn of events, reaction, or endorsement of a specific matter or practice. It is intended to stay up with individual security and thrive, yet it can likewise make unfriendly impacts. Restrictive practice ought to be taken on. In any case, assuming that such practices are fundamental, it is essential to utilize them cautiously and reasonably. In this research, there are multiple restrictive practices that benefit medical services suppliers, and the rules for such practices are either established by higher authorities or by nurses themselves.

Needless to say, most medical professionals in this profession have a true mission to care for people. As such, the idea of handcuffing patients against their will is often against the personal and professional ethics of some frontline mental health workers. Such professionals may face ethical dilemmas when they encounter caregivers. Self-harm or when non-invasive de-escalation strategies are ineffective (Griffiths et al. 2022). Cognitive dissonance is therefore associated with medical professionals who engage in restraints to prevent further harm to residents but are uncomfortable with the process of manually restraining people against their will within a care home (Duffy and Kelly, 2020). Therefore, where restrictive practices are employed to prevent residents from engaging in further self-harm, it is best to support frontline staff when they feel that restraint violates their professional ethics. the method must be considered.

Physical restraints are utilized to restrict the patient's turn of events and are regularly shown in circumstances where the patient's activities represent a danger to their own security or the prosperity of others. These ought to possibly be utilized for brief timeframes when all else fizzles. It is critical to guarantee that the patient's solace and equilibrium are kept up with while they are really confined.

Medication management boards are actually looking at patients' medications to guarantee they are taking the ideal dosage at the best time. This ought to be conceivable by using pill dispensers, solutions or by conveying drugs straightforwardly to the patient.

Seclusion or confinement implies bringing the patient into a space or region where they can't be. It is by and large utilized in circumstances where the patient's conduct represents a risk to their own security or the well-being of others. Confinement ought to possibly be utilized when all else fizzles and ought to be firmly seen to guarantee patient well-being.

The environmental change includes changing the patient's ongoing circumstances to decrease the risk of injury or mischief. This might incorporate eliminating sharp and risky articles from the patient room or introducing well-being gadgets, for example, bedrails and tipping mats. Changing the environment might assist with diminishing the risk of patient injury or damage.

7.6 Limitation

Correspondence with the Directorate incorporates observing patient reactions to lessen the risk of damage. This might incorporate limiting the patient's admittance to specific people or articles that might incite the patient to act. It is essential to guarantee that consistency checks are performed just when vital and that all understanding correspondences are thought of.

Furthermore, restricted practices assist with guaranteeing patient prosperity and prosperity. Anyway, it is critical to utilize such practices sensibly and just when vital. Guardians ought to know about the conceivable unfavorable impacts of restricted conduct and guarantee that patients are constantly approached with deference and quiet. Guardians can utilize a blend of useful and denied practices to guarantee their patients get the most ideal consideration.

In the medium secure units, there are several restrictive practices that have been implied to patients for their safety and speedy recovery. Most of those practices are set keeping in mind the patients ' activities. There are certain restrictive practices that are set to provide benefits to nurses working in forensic secure units. These restrictive practices are mostly set to reduce the pressure on the nurses as in most medium security wards there is a scarcity of nurses (Higgins, 2021). This shortage of nurses is fulfilled by establishing some rules related to the restrictive approach. The nurses are the pillars of medium secure units as they single-handedly tackle patients admitted to the ward. They have tremendous pressure on patients ' safety for which they require a good amount of workforce although it is absent.

Patients inside the ward are restricted to roam freely around the ward or in the garden. This is a restrictive approach that is implied by nurses to the wards. The main reason behind this implementation is the staff shortage which is faced by almost all mediums secure wards. Generally, the nurses monitor patients all the time to assure the reduction of escape risk and injury-related risks. The shortage of staff cause inefficient monitoring of patients which affects their working ability. Implementation of this rule effectively reduces the chance of occurring damage to patients along with the chance of escape from the ward (Duff et al. 2023). Due to high levels of aggression and anger, it is often seen that patients are involved in fighting or other nuisances while they roam in the garden or in the ward. It is difficult to control them during that time and they can possess a serious threat to other patients as well as nursing staff. Keeping in mind, this restrictive practice reduces the burden on nurses. For nurses, it is difficult to keep tracking patients ' different activities at the same time, as there is less staff in the ward. Restrictive practices which force patients to maintain a disciplined lifestyle ease the work of the nurses. Doing the same activities at a particular time is helpful for them to monitor and assess patients ' activities. These restrictive practices sometimes violate patients ' basic human rights but are very much useful for them to perform their duty in an efficient manner (McSherry, and Maker, 2020). Although some experienced nurses unofficially modify the rules for the sake of their patients, they try to maintain discipline within the ward so that there is no disturbance in providing patients with proper care.

7.7 Recommendation

The interview session provides various information on restrictive practices in forensic medium care. Based on the accumulated information, there are multiple problems that affect the flow of restrictive practices in the medium care units. After analyzing these issues, there are some suggestions that can reduce the risk of problems. The first issue, which is mentioned by multiple participants, is the application of blanket rules. The nurses should not apply the blanket rule in a generalized form. In the medium secure services, there are numerous patients with different requirements and health conditions. Generalized blanket rules do not work as effectively as person-centered blanket rules. The use of personalized blanket rules can effectively help in the recovery process of patients. Furthermore, it also helps to fulfill the necessities of patients individually. In addition, the use of personalized blanket rules can effectively reduce the extra burden on the patients as there are often some highly restricted rules which are implied to all patients. But in some particular cases, there are certain rules which need to be applied as a generalized form. Particularly in that cases, blanket rules can be applied in general to control some common activities of patients.

Brief discussion on link between recommendation and limitation

The utilization of seclusion as a disallowed practice in mid-care units is a confounding subject that requires cautious thought. While fundamental in specific conditions, seclusion can likewise influence patients. Consequently, as a last resort, seclusion ought to be performed while all excess choices have been depleted and there is an irrefutable risk of misbehaviors to the patient or others. To restrict the utilization of detachment in medium-sized care units, an unmistakable methodology and further developed frameworks for the utilization of segregation, remembering severe standards for when separation is proper, documentation necessities, and check strategies. is required. The nursing staff should be constantly ready for critical decision techniques to address problematic ways of behaving, de-escalation technique, productive input, and regular change. What's more, senior experts should guarantee satisfactory staffing levels to guarantee sufficient patient perception and backing. Ordinary reaction and collaboration ought to be laid out among staff, patients, and families to recognize risky social triggers and work with ways of tending to them.

Also, nurses ought to survey and assess the utilization of seclusion, including the number of cases, the season of seclusion, and patient results. Essentially, making a system for isolation case subtleties and examinations is a compelling method for recognizing regions that need improvement and guaranteeing that essential isolation is fittingly used. Utilization of particular interventions like sensory rooms or formative activities ought to be considered to establish a protected and quiet climate for the patient. It is essential to comprehend that the act of seclusion ought to be proceeded with in view of every patient's singular requirements and condition. Isolating ought to just be finished after all leftover choices have been depleted when all else has fizzled. Staff ought to be reliably ready for elective methods to resolve issues and ways of behaving, and patients and families ought to be associated with the treatment dynamic interaction. These cures can restrict the utilization of separating in medium-sized care units and address enduring outcomes.

Forensic secure units ' staff deficiency is a huge issue that can influence the degree of patient consideration and parental security. To tackle this issue, experts should expand their staff. One of the most outstanding ways of taking care of the staff deficiency issue is to build the labor force. This can be accomplished by employing and enrolling extra nurses, making motivators to hold existing nurses, and tending to working circumstances. Arranged planning and backing practices for working paramedics are required. Clinical partners in medium secure units require exceptional readiness and support to deal with the perplexing necessities of their patients effectively. The forensic care should furnish its nurses with a continuous planning and backing system to foster the abilities and data they need to work in this climate. Furthermore, more significant positions and parental figures ought to exploit development and robotization. Utilizing development and computerization smoothes out processes and diminishes representative risk. This might incorporate the utilization of electronic clinical records, mechanized medical care systems, and different advances that assist with expanding efficiency and decreasing guardianship issues.

Furthermore, participation with neighborhood associations requires legitimate thought. Co-building organizations with provincial affiliations can give extra advantages and backing the staff of the Forensic Security Unit may incorporate relationships with different associations that can uphold. One more impressive method for extending portrayal is by building wage rates and advantages. Law offices are frequently understaffed because of low wages and unacceptable advantages. More noteworthy remuneration and advantages help draw in and hold qualified staff and address the comprehensive idea of patient consideration. Also, a versatile schedule should be stuck to. By running versatile timetables, agents become more adroit and kill staffing bottlenecks. This might incorporate part-time adaptable plans for getting work done that help draw in and hold qualified staff. Work ought to be finished on the functioning states of the well-being of laborers. Further improvement of working circumstances, for example, give a protected and stable work environment, draw in and hold qualified staff, and address the overall idea of patient consideration. Tending to staff deficiencies in forensically-safe units is accordingly fundamental to guarantee that patients get the greatest possible level of consideration. The hospitals should be focused on refreshing staff, planning and supporting them, utilizing development and computerization, building joins with neighborhood sections, extending pay and advantages, offering adaptable schedules, and working on working circumstances. , the hospital can fix this issue and work on calm outcomes.

The management authorities should employ more nursing staff and caregivers to assist and reduce the pressure on the existing nurses in medium secure units. They can use specific criteria that can help to identify the particular group of nurses who are eligible to work in medium secure units.

In this recommendation section for the research paper, relevant findings from the ‘care and control ' approach with appropriate knowledge. From the group discussion aspect, participants discussed more subtle ‘restrictive practices encountered on the ward '. They noted that extensive restrictive practices varied from ward to ward. In interviews, competition constructs it challenging to analyze ‘between basic and less necessary restrictions '. However, they were certain that a few restrictive measures were basic to assure others and ensure the safety of the ward. In contrast, ‘they also stressed that a few restrictive practices violate patients' liberties and rights '. In this aspect suggestions for considering nurse's activities and dealing with the patients properly. The development of restrictive practices is recommended for future activities participants discussed more subtle restrictive practices encountered on the ward. They noted that extensive restrictive practices varied from ward to ward. In interviews, competition constructs it challenging to analyze between basic and less necessary restrictions. However, they will be more certain that ‘a few restrictive measures ' will be basic to assure others and ensure the safety of the ward. In contrast, also stressed that a few restrictive practices violate patients' liberties and rights.

7.8 Future Scopes

Future research is likely to focus primarily on the impression that medical caretakers have of restrictive clinical practices. The future examination might zero in on what prohibitive practices mean for attendants ' work fulfillment, feelings of anxiety, burnout, and generally speaking prosperity. This review can direct the improvement of procedures to decrease the adverse consequences of prohibitive practices by recognizing the specific viewpoints that greatly affect nurture. It 's possible that guidelines that explain when restrictive practices should be used in healthcare settings and are based on evidence will receive more attention. Based on scientific evidence and patient-centered considerations, these guidelines can assist in ensuring that restrictive practices are used sparingly. The empowerment of nurses to actively participate in decision-making processes regarding restrictive practices may be the focus of future efforts. In order for nurses to effectively advocate for patient 's rights and well-being, this may necessitate increasing their education and training in ethical considerations, alternative interventions, and communication techniques. In the future, it may become more important to work together in teams and across disciplines to solve problems caused by restrictive practices. This could incorporate empowering better correspondence and cooperation between clinical collaborators, specialists, examiners, social laborers, and different specialists in clinical consideration to foster smart plans that limit the requirement for unsafe practices. A more grounded accentuation on moral contemplations and the improvement of patient-focused care may be remembered for the resulting expansion. Medical attendants may focus on practices that are prohibitive, similar to moral standards like independence, advantage, and the cheapest option. Endeavors could be facilitated to ensure that patients ' honor, respectability, and inclinations are considered while changing the necessities for good well-being and effective consideration. Future research and initiatives may focus on influencing approaches and administrative changes to address the issues posed by prohibitive practices. This could entail advocating for the creation of standardized protocols, elucidating guidelines, and monitoring systems to ensure that restrictive practices are utilized appropriately and to prevent their misuse or excessive use. Future research on how medical attendants feel about restrictive clinical practices is likely to focus on advancing patient-centered care, moral considerations, interdisciplinary collaboration, and getting medical attendants involved in effective dynamic cycles related to restrictive practices. It is hoped that prohibitive practices will have fewer adverse effects on medical caregivers and patients while preserving a secure environment for medical care by addressing these issues.

There are various future scopers of restrictive practices. Further research in this field is important to enhance the further future scope of this field. Restrictive practices suggest to activities or arrangements that limit rivalry in the commercial center, frequently to the disadvantage of customers. Price fixing, sharing of the market, exclusive dealing, and collusion between rivals are examples of these practices. Regulators all over the world have been concerned about restrictive practices, but the scope of those practices in the future will be determined by a variety of factors. Anti-competitive agreements and price fixing aii are included in this restrive practice in the field of medicine. Restrictive practices in the medical field which means, a monopolistic way of behaving, value fixing, and hostility to cutthroat arrangements, have been a subject of worry in medical services frameworks around the world. While these practices might have momentary advantages for specific partners, they can impede contests, limit patient decisions, and expand medical care costs. The future extent of prohibitive practices in the clinical field is probably going to confront expanding examination and guidelines. Healthcare anti-competitive practices are increasingly being identified and addressed by regulators and policymakers. They are aware that such practices have a negative effect on the well-being of patients and the overall cost of healthcare. For future use, stricter penalties and more enforcement actions are likely. Traditional healthcare models could be upended by the rapid development of AI-driven diagnostics, digital health solutions, and telemedicine. Patients and providers may resist restrictive prwell-beinghat prevent the use of these technologies as they seek alternatives that are more affordable and accessible. Patients are at the center of healthcare decisions as a result of the shift toward patient-centered care. Because of this emphasis on patient choice and empowerment, there will probably be pressure to get rid of restrictive practices that make it hard for patients to choose between different providers or treatment paths or force them to use certain ones. To effectively combat restrictive practices, healthcare requires international collaboration due to its global nature. Associations like the World Wellbeing Association (WHO) and provincial administrative bodies are probably going to reinforce endeavors to blend guidelines and offer prescribed procedures, expecting to wipe out enemies of cutthroat ways of behaving across borders.

A highly debated issue is the direction of nursing educational standards. The standards and regulations for nursing education have needed to be reviewed in light of legislative modifications and technological improvements over time. The function of colleges and universities in nursing education must therefore be reviewed. The nursing educational standards are anticipated to change as a result of new initiatives and innovations in the next years. Communications, data, and patient care automation innovations will be the driving forces behind these developments. For instance, virtual patient diagnosis is anticipated to be included into nursing curricula, offering a more engaging educational environment. The breadth of patient diagnosis and therapy may also be improved and expanded with the help of machine learning and artificial intelligence. This might result in better clinical judgement in the classroom and better patient outcomes.

Further, to guarantee that nursing students are being taught in accordance with accepted best practises, evidence-based practise in nursing must be implemented. Making judgements about patient care under this theory entails using the best available data from both research and clinical investigations. Therefore, integrating evidence-based practise into nursing courses will be essential in developing the skills and abilities necessary to provide patients with great care.

New rules could be implemented that would alter the educational requirements now in place. For instance, in order to enhance safety and care quality, the federal government should enact modifications that address nurse-patient ratios. Similar attempts may be made to alter the typical nurse-patient connection and implement fresh nursing techniques that put the needs of the patient first. The establishment of legislation that facilitate non-traditional students' access to nursing education, such as working adults, is another possibility. These modifications will probably help a bigger number of people have better access to high-quality healthcare. Lastly, it is anticipated that advancements in nursing research may influence future changes to the requirements for nursing education. The establishment of new or revised standards will be influenced by research studies on evidence-based practises, such as the incorporation of cutting-edge technologies into nursing curricula. Further, nursing research can provide light on the issues that need to be resolved to raise the standard and safety of care in healthcare facilities. The possibility of nursing education's future is fascinating. However, it is crucial that educational standards are consistently upheld, amended, and enhanced in order to guarantee that the future of healthcare is well-served. One of the main forces behind these changes is anticipated to be the application of evidence-based practise in the classroom, combined with new initiatives and policy changes. In the end, more qualified nurses who can deliver high-quality care to patients can be developed by continuing to push for greater standards in nursing education.

To identify solutions that lessen the usage of these practises in mental health settings, it is crucial to understand how psychiatric nurses perceive restrictive practises. To delve deeper into this subject, more research should be done. Future studies can concentrate on elements, such as attitudes of other medical professionals, workplace culture, or accessibility to alternative therapies, that affect psychiatric nurses' perceptions of restrictive practises. The effect of psychiatric nurse education on their opinions of restricted practises could also be studied. Studies could compare the perceptions of nurses with backgrounds in general nursing and those with backgrounds in mental health nursing to see whether there are any differences. This study could be expanded to examine the ways in which restricted practises are used in different nations. This research may be able to better understand the ways that various cultures see and employ particular practises by comparing the employment of restrictive practises across various countries. Further investigation can also concentrate on analysing the mental health experiences of patients who are subjected to restricted practises. The usage of restrictive practices, how it affects patient care must be understood from the patient's point of view.

7.9 Summary

In this entire chapter of this research paper, there have been differing opinions among healthcare professionals, “medical quality commissioners (CQCs)”, staff, family/caregivers, and patients about the value of restrictive procedures in safe forensics departments. These obstructions include broader practices such as the introduction of general rules that restrict individual rights and freedoms, such as denying access to desire. This results in a large disparity in restrictive practices “(considered restrictive practices/interventions)” in medium-security male wards. The implementation of restrictive practices varies widely between hospitals and wards in the types and frequency of practices adopted (Caseby et al. 2022). A report on the state of care in mental health services found differences in the way staff adopted restrictive practices when dealing with difficult behaviors. They have also expressed concern that care for some patients was too restrictive. In my clinical experience, the two main terms used to describe restrictive procedures in moderate security hospitals have been restrictive practice and blanket rules, but these are vague and misleading.

This is indeed confusing, especially for a few caregivers ‘who may be undisciplined ' and ‘change resistant ' to this intervention. Since most forensic psychiatric patients commit crimes, this becomes even more important when considering boundary awareness. They do favors and employ staff when their behavior is inconsistent. This can create divisions within teams, good nurses and bad nurses, and open the door for accusations about nursing practice. Most of the male secondary security service patients are characterized as having violated laws, organizational rules, or someone else's organs, which often means redress for the harmed violation (McKenna Lawson, 2022). Patients in medium-security facilities are typically detained after consent, mandated for treatment, and often see themselves as targets of the system.

Restrictive practices are tools for frontline nursing staff to maintain the safety of the “Forensic Men's Medium Safety Services” ward. This chapter discusses and describes the research methodology used in this phenomenological study to justify the implementation of restrictive practices in male secondary security services. This is related to frontline nurse perceptions, understanding, attitudes, and practices, some of which are considered restrictive practices/interventions or overarching rules, or are overly viewed. will highlight the difference. describe the research design and justification of the project, data collection, and analysis methods and approaches, supported by the best available literature. Finally, research limitations and a role in the workplace “(Clinical Nurse Manager)” allow me to be a worker/researcher or an insider researcher (Schlag et al. 2020). A researcher's professional mandate may limit the information provided by staff. Power differences can disrupt workplace relationships and, as a result, undermine research results. However, other sections of this chapter continue with extensive discussions, particularly on ethical issues, biases in the research process, and choice of method.

Ethical approval processes and participant selection will also be in focus. Instructions will be given to streamline the use of semi-structured interviews and focus groups in the study. Important reflections on data collection activities, such as limitations and participant demographics, are shown. The research site was the “UK-based NHS Trust's medium security male forensic department. Description and analysis of the data collection implementation used in the study. Also advertised the location of the study and the context in which the study was conducted, including the member population. Issues related to talent shortages were also discussed.

The summary of this chapter reports on emerging issues arising from the perception of mental health nurses (RMNs). As a structure for participants' descriptions of specific experiences and perceptions that researchers consider relevant to their research question (Adamson et al. 2020). Analysis of participants' real-life experiences involved reading transcribed interviews multiple times, ensuring they were relevant to answering questions about restrictive practices. Nineteen participants participated in individual interviews or focus groups. Participants were divided into two categories for her, 13 for personal interviews and 6 for her discussions in focus groups. Semi-structured interviews and focus group discussions were conducted with accomplished nurses who had completed psychiatric nursing discipline and had action employed in a medium security forensic hospital (Blackburn et al. 2019). Six of the participants in the one-on-one interviews were female and the remaining seven were male. Two women and four men participated in the focus group. Some of the participants were created at a medium-security men's forensic hospital from six months to five years, and others more than five years.

The evidence-based form used to reduce restrictive practices in this analytic area is safety wards. Protective stations have many models a certain can be made-to-measure to original stations to reduce attack and assault within the station. It includes sections such as “Mutual Expectations, Recovery, Safety, and Personal Expectations” and is developed in association with staff along with patients facing assured ward safety. The procedures are jointly created by staff and patients, along with these procedures are developed and agreed upon as an act of employment together. In a reasonably safe environment, training assures that bondage is safely practiced (Stajduhar et al. 2020). “Prevention Management of Violence and Aggression (PMVA) training”, “Personal Protective Equipment (PPE)”, ‘Forensic Safety Training, and PPE Response Training ensure ' that restrictive practices are conducted in accordance with Trust policy and do not violate human rights law provided.

The process of evaluating participant responses was divided into individual group discussions and focus group discussions. Responses to the interviews explained the opportunities of the current regulations, helped confirm the effectiveness of the regulations for both patients and staff, the applicability of every regulation, and also helped some of the staff beneficiaries to object to the regulations. It is also useful for chanting. Analysis of the interview responses identifies some of the more important factors in the situation. These aspects are related to care plans, policies, regulations, and medical facilities that can provide adequate backing to advance restrictive caregiver practices (Zinser et al. 2022). Patient concerns are the most important criterion in this practice. From interviews with nurses, we learned that it is important for all patients to review their daily plans to help them choose specific activities for the day. During these interviews, the patient's psychological state is regularly evaluated. Additionally, these meetings are important for gaining access to community vacations. After all, social dismissal is impossible without assessing the patient's mental state, otherwise, serious injuries and accidents can occur. Regular patient interviews provide patients with a variety of opportunities to take social leave.

References

Journals

Griffiths, R., Dawber, A., McDougall, T., Midgley, S. and Baker, J., 2022. Non?restrictive interventions to reduce self?harm amongst children in mental health inpatient settings: Systematic review and narrative synthesis. International journal of mental health nursing, 31(1), pp.35-50.

Wolverson, E., Harrison Dening, K., Gower, Z., Brown, P., Cox, J., McGrath, V., Pepper, A. and Prichard, J., 2023. What are the information needs of people with dementia and their family caregivers when they are admitted to a mental health ward and do current ward patient information leaflets meet their needs?. Health Expectations.

Sacre, M., Albert, R. and Hoe, J., 2022. What are the experiences and the perceptions of service users attending Emergency Department for a mental health crisis? A systematic review. International Journal of Mental Health Nursing, 31(2), pp.400-423.

Ashley, L., Spencer, K. and Neal, R., 2022. Cancer Detection, Diagnosis, Treatment, and Care for People with Dementia: an overview of current knowledge, research, and practice recommendations. CA: A Cancer Journal for Clinicians.

Goulet, M.H., Cassivi, C., Hupé, C., Jean-Baptiste, F. and Dumais, A., 2023. Seclusion and mechanical restraint in the wake of the COVID-19 pandemic: an increased use in mental health settings.

Caseby, S.C.L., Woodhouse, F.A., Montgomery, S.M., Kroes, M.A. and Duddy, M.E., 2022. Transition to secondary progressive multiple sclerosis: The consequences for patients and healthcare systems, a healthcare professional survey. Health Science Reports, 5(1), p.e474.

McKenna Lawson, S., 2022. How we say what we do and why it is important: An idiosyncratic analysis of mental health nursing identity on social media. International Journal of Mental Health Nursing, 31(3), pp.708-721.

Schlag, A.K., Baldwin, D.S., Barnes, M., Bazire, S., Coathup, R., Curran, H.V., McShane, R., Phillips, L.D., Singh, I. and Nutt, D.J., 2020. Medical cannabis in the UK: From principle to practice. Journal of Psychopharmacology, 34(9), pp.931-937.

Adamson, J., Kinnaird, E., Glennon, D., Oakley, M. and Tchanturia, K., 2020. Carers ' views on autism and eating disorders comorbidity: qualitative study. BJPsych Open, 6(3), p.e51.

Stajduhar, K.I., Giesbrecht, M., Mollison, A., Dosani, N. and McNeil, R., 2020. Caregiving at the margins: An ethnographic exploration of family caregivers experiences providing care for structurally vulnerable populations at the end-of-life. Palliative Medicine, 34(7), pp.946-953.

Zinser, J., Hale, L. and Jones, C., 2022. Distress Tolerance and Family Accommodation: Associations in Parents of Young People with Eating Disorder Behaviours.

Savarimuthu, D., 2020. A hermeneutic phenomenological exploration of nurses' experience: positive behaviour support (Doctoral dissertation, Salford University).

Kelley, R., Godfrey, M. and Young, J., 2021. Knowledge exchanges and decision-making within hospital dementia care triads: An ethnographic study. The Gerontologist, 61(6), pp.954-964.

Nicaise, P., Giacco, D., Soltmann, B., Pfennig, A., Miglietta, E., Lasalvia, A., Welbel, M., Wciorka, J., Bird, V.J., Priebe, S. and Lorant, V., 2020. Healthcare system performance in continuity of care for patients with severe mental illness: A comparison of five European countries. Health Policy, 124(1), pp.25-36.

Solberg, M., Berg, G.V. and Andreassen, H.K., 2023. Lost in the loop-A qualitative study on patient experiences of care in standardized patient pathways.

Al-Busaidi, I.S., Al Suleimani, S.Z., Dupo, J.U., Al Sulaimi, N.K. and Nair, V.G., 2019. Nurses ' knowledge, attitudes, and implementation of evidence-based practice in Oman: A multi-institutional, cross-sectional study. Oman medical journal, 34(6), p.521.

Griffith, J.J., Meyer, D., Maguire, T., Ogloff, J.R. and Daffern, M., 2021. A clinical decision support system to prevent aggression and reduce restrictive practices in a forensic mental health service. Psychiatric services, 72(8), pp.885-890.

Griffiths, R., Dawber, A., McDougall, T., Midgley, S. and Baker, J., 2022. Non?restrictive interventions to reduce self?harm amongst children in mental health inpatient settings: Systematic review and narrative synthesis. International journal of mental health nursing, 31(1), pp.35-50.

Leif, E.S., Fox, R.A., Subban, P. and Sharma, U., 2023. ‘Stakeholders are almost always resistant ': Australian behaviour support practitioners ' perceptions of the barriers and enablers to reducing restrictive practices. International Journal of Developmental Disabilities, 69(1), pp.66-82.

Magnusson, E., Axelsson, A.K. and Lindroth, M., 2020. ‘We try '–how nurses work with patient participation in forensic psychiatric care. Scandinavian journal of caring sciences, 34(3), pp.690-697.

Parker, B., Swift, E. and Gkika, S., 2022. Staff and service users' experiences of the self-harm pathway on an acute inpatient ward. British Journal of Mental Health Nursing, 11(2), pp.1-10.

Perruchoud, E., Fernandes, S., Verloo, H. and Pereira, F., 2021. Beliefs and implementation of evidence?based practice among nurses in the nursing homes of a Swiss canton: An observational cross?sectional study. Journal of clinical nursing, 30(21-22), pp.3218-3229.

Sustere, E. and Tarpey, E., 2019. Least restrictive practice: its role in patient independence and recovery. The Journal of Forensic Psychiatry & Psychology, 30(4), pp.614-629.

Wood, L., Alonso, C., Morera, T. and Williams, C., 2021. The evaluation of a highly specialist inpatient psychologist working with patients with high risk presentations in an acute mental health inpatient setting. Journal of Psychiatric Intensive Care, 17(1), pp.29-40.

Chiodo, L.M., Cosmian, C., Pereira, K., Kent, N., Sokol, R.J. and Hannigan, J.H., 2019. Prenatal alcohol screening during pregnancy by midwives and nurses. Alcoholism: Clinical and Experimental Research, 43(8), pp.1747-1758.

Both-Nwabuwe, J.M., Lips-Wiersma, M., Dijkstra, M.T. and Beersma, B., 2020. Understanding the autonomy–meaningful work relationship in nursing: a theoretical framework. Nursing outlook, 68(1), pp.104-113.

Fisher, M. and Kiernan, M., 2019. Student nurses' lived experience of patient safety and raising concerns. Nurse Education Today, 77, pp.1-5.

Moilanen, T., Kangasniemi, M., Papinaho, O., Mynttinen, M., Siipi, H., Suominen, S. and Suhonen, R., 2021. Older people 's perceived autonomy in residential care: An integrative review. Nursing ethics, 28(3), pp.414-434.

Duxbury, J., Baker, J., Downe, S., Jones, F., Greenwood, P., Thygesen, H., McKeown, M., Price, O., Scholes, A., Thomson, G. and Whittington, R., 2019. Minimising the use of physical restraint in acute mental health services: the outcome of a restraint reduction programme (‘REsTRAIN YOURSELF '). International journal of nursing studies, 95, pp.40-48.

Cho, H., Sagherian, K. and Steege, L.M., 2021. Hospital nursing staff perceptions of resources provided by their organizations during the COVID-19 pandemic. Workplace Health & Safety, 69(4), pp.174-181.

Sarzynski, E. and Barry, H., 2019. Current evidence and controversies: advanced practice providers in healthcare. Am J Manag Care, 25(8), pp.366-368.

Alsubaie, S., Temsah, M.H., Al-Eyadhy, A.A., Gossady, I., Hasan, G.M., Al-Rabiaah, A., Jamal, A.A., Alhaboob, A.A., Alsohime, F. and Somily, A.M., 2019. Middle East Respiratory Syndrome Coronavirus epidemic impact on healthcare workers ' risk perceptions, work and personal lives. The Journal of Infection in Developing Countries, 13(10), pp.920-926.

Lim, E., Wynaden, D. and Heslop, K., 2019. Changing practice using recovery?focused care in acute mental health settings to reduce aggression: A qualitative study. International journal of mental health nursing, 28(1), pp.237-246.

Durkin, J., Usher, K. and Jackson, D., 2019. Embodying compassion: A systematic review of the views of nurses and patients. Journal of Clinical Nursing, 28(9-10), pp.1380-1392.

Kydonaki, K., Kean, S. and Tocher, J., 2020. Family INvolvement in inTensive care: A qualitative exploration of critically ill patients, their families and critical care nurses (INpuT study). Journal of Clinical Nursing, 29(7-8), pp.1115-1128.

Hossain, M.A., Rashid, M.U.B., Khan, M.A.S., Sayeed, S., Kader, M.A. and Hawlader, M.D.H., 2021. Healthcare workers' knowledge, attitude, and practice regarding personal protective equipment for the prevention of COVID-19. Journal of multidisciplinary healthcare, pp.229-238.

Meaklim, H., Jackson, M.L., Bartlett, D., Saini, B., Falloon, K., Junge, M., Slater, J., Rehm, I.C. and Meltzer, L.J., 2020. Sleep education for healthcare providers: Addressing deficient sleep in Australia and New Zealand. Sleep Health, 6(5), pp.636-650.

Duffy, R.M. and Kelly, B.D., 2020. Can the World Health Organisation 's ‘QualityRights ' initiative help reduce coercive practices in psychiatry in Ireland?. Irish journal of psychological medicine, pp.1-4.

Silvera, G.A., Wolf PhD, J.A., Stanowski, A. and Studer, Q., 2021. The influence of COVID-19 visitation restrictions on patient experience and safety outcomes: A critical role for subjective advocates. Patient Experience Journal, 8(1), pp.30-39.

Blackburn, J., Ousey, K. and Stephenson, J., 2019. Nurses ' education, confidence, and competence in appropriate dressing choice. Advances in skin & wound care, 32(10), pp.470-476.

Squires, A., Murali, K.P., Greenberg, S.A., Herrmann, L.L. and D 'amico, C.O., 2021. A scoping review of the evidence about the nurses improving care for healthsystem elders (NICHE) program. The Gerontologist, 61(3), pp.e75-e84.

Slettmyr, A., Schandl, A. and Arman, M., 2019. The ambiguity of altruism in nursing: A qualitative study. Nursing ethics, 26(2), pp.368-377.

Paffenholz, P., Peine, A., Hellmich, M., Paffenholz, S.V., Martin, L., Luedde, M., Haverkamp, M., Roderburg, C., Marx, G., Heidenreich, A. and Trautwein, C., 2020. Perception of the 2020 SARS-CoV-2 pandemic among medical professionals in Germany: results from a nationwide online survey. Emerging microbes & infections, 9(1), pp.1590-1599.

Verger, P., Scronias, D., Dauby, N., Adedzi, K.A., Gobert, C., Bergeat, M., Gagneur, A. and Dubé, E., 2021. Attitudes of healthcare workers towards COVID-19 vaccination: a survey in France and French-speaking parts of Belgium and Canada, 2020. Eurosurveillance, 26(3), p.2002047.

Lamb, C., Evans, M., Babenko?Mould, Y., Wong, C. and Kirkwood, K., 2019. Nurses ' use of conscientious objection and the implications for conscience. Journal of advanced nursing, 75(3), pp.594-602.

Ament, S.M., Couwenberg, I.M., Boyne, J.J., Kleijnen, J., Stoffers, H.E., van den Beuken, M.H., Engels, Y., Bellersen, L. and Janssen, D.J., 2021. Tools to help healthcare professionals recognize palliative care needs in patients with advanced heart failure: A systematic review. Palliative medicine, 35(1), pp.45-58.

Verger, P., Scronias, D., Dauby, N., Adedzi, K.A., Gobert, C., Bergeat, M., Gagneur, A. and Dubé, E., 2021. Attitudes of healthcare workers towards COVID-19 vaccination: a survey in France and French-speaking parts of Belgium and Canada, 2020. Eurosurveillance, 26(3), p.2002047.

Charette, M., Goudreau, J. and Bourbonnais, A., 2019. Factors influencing the practice of new graduate nurses: A focused ethnography of acute care settings. Journal of Clinical Nursing, 28(19-20), pp.3618-3631.

Vellone, E., De Maria, M., Iovino, P., Barbaranelli, C., Zeffiro, V., Pucciarelli, G., Durante, A., Alvaro, R. and Riegel, B., 2020. The self?care of heart failure index version 7.2: Further psychometric testing. Research in Nursing & Health, 43(6), pp.640-650.

Alqahtani, A.J. and Mitchell, G., 2019, June. End-of-life care challenges from staff viewpoints in emergency departments: systematic review. In Healthcare (Vol. 7, No. 3, p. 83). MDPI.

Curran, V., Gustafson, D.L., Simmons, K., Lannon, H., Wang, C., Garmsiri, M., Fleet, L. and Wetsch, L., 2019. Adult learners ' perceptions of self-directed learning and digital technology usage in continuing professional education: An update for the digital age. Journal of Adult and Continuing Education, 25(1), pp.74-93.

Stevens, L. and Wurf, G., 2020. Perceptions of inclusive education: A mixed methods investigation of parental attitudes in three Australian primary schools. International Journal of Inclusive Education, 24(4), pp.351-365.

Dugué, M., Sirost, O. and Dosseville, F., 2021. A literature review of emotional intelligence and nursing education. Nurse Education in Practice, 54, p.103124.

Woo, M.W.J. and Li, W., 2020. Nursing students' views and satisfaction of their clinical learning environment in Singapore. Nursing Open, 7(6), pp.1909-1919.

Labrague, L.J., McEnroe?Petitte, D.M. and Tsaras, K., 2019. Predictors and outcomes of nurse professional autonomy: A cross?sectional study. International journal of nursing practice, 25(1), p.e12711.

Lasalvia, A., Bonetto, C., Porru, S., Carta, A., Tardivo, S., Bovo, C., Ruggeri, M. and Amaddeo, F., 2021. Psychological impact of COVID-19 pandemic on healthcare workers in a highly burdened area of north-east Italy. Epidemiology and psychiatric sciences, 30, p.e1.

Saleh, M.Y., Papanikolaou, P., Nassar, O.S., Shahin, A. and Anthony, D., 2019. Nurses' knowledge and practice of pressure ulcer prevention and treatment: an observational study. Journal of tissue viability, 28(4), pp.210-217.

Zhan, Y.X., Zhao, S.Y., Yuan, J., Liu, H., Liu, Y.F., Gui, L.L., Zheng, H., Zhou, Y.M., Qiu, L.H., Chen, J.H. and Yu, J.H., 2020. Prevalence and influencing factors on fatigue of first-line nurses combating with COVID-19 in China: a descriptive cross-sectional study. Current medical science, 40, pp.625-635.

Burgess, A., Breman, R.B., Bradley, D., Dada, S. and Burcher, P., 2021. Pregnant women's reports of the impact of COVID-19 on pregnancy, prenatal care, and infant feeding plans. MCN: The American Journal of Maternal/Child Nursing, 46(1), pp.21-29.

O 'Connor, S.R., Connaghan, J., Maguire, R., Kotronoulas, G., Flannagan, C., Jain, S., Brady, N. and McCaughan, E., 2019. Healthcare professional perceived barriers and facilitators to discussing sexual wellbeing with patients after diagnosis of chronic illness: A mixed-methods evidence synthesis. Patient Education and Counseling, 102(5), pp.850-863.