Discussion
The findings of our study provide an overarching theme
and three related themes depicting their experiences of,
and views about, usage of these practices. The overarching
theme, lack of accessible alternatives to restraint and
seclusion, encapsulates that these measures, although
regarded as a last resort, were perceived as the only effective,
accessible means participants had to manage aggression
when it did not respond to less intensive
interventions. Reluctance to eliminate these practices has
also been reported elsewhere in Australia (Johnson et al.
2009) and the UK (Perkins et al. 2012). The principal
reasons for reluctance in the present study were perceptions
about lack of effectiveness of alternative measures
and concern about safety, and these concerns have been
reported elsewhere (Chien & Lee 2007). What these findings
suggest, though, is a lack of understanding of, and
education about, effective alternatives to restraint and
seclusion (Smith et al. 2005, Moore & Haralambous
2007), and a lack of consideration of ethical issues surrounding
these practices. They also highlight a dichotomy
between recommendations of national reports in Australia
to reduce and, where possible, eliminate these practices
(National Mental Health Working Group 2005, National
Mental Health Commission 2012) and actual clinical
practice. Moreover, while these national reports emphasize
that people should be cared for in the least restrictive
environment, the findings of this study highlight a further
dichotomy with the reality of clinical practice.
The first related theme, an adverse interpersonal environment
contributing to use of restraint and seclusion,
emphasizes the importance of good staff-to-patient behaviours
and communication in addressing aggression. The
value of good staff-to-patient interaction has also been
highlighted in a UK study of staff attitudes towards aggression
in residential care settings for elderly people with