Exploring psychological safety in adult inpatient mental healthcare. How does restrictive practice impact psychological safety?

In inpatient mental health services, restrictive practices are used to contain risk and maintain physical safety on wards but have shown to negatively impact patient wellbeing and trust. Researchers and professionals suggest mental health care often focuses on the physical safety of patients at the expense of psychological safety. There are two important gaps in the current literature: 1) an understanding of what psychological safety means to patients in inpatient mental health services, and 2) what is the relationship between restrictive practices and psychological safety. The overall aim of this thesis was to understand how restrictive practices can be made more psychologically safe for patients in inpatient mental health services. This thesis used an exploratory qualitative design comprising four studies, where the findings of each study informed the development of the next. A systematic review (Study 1) of published qualitative research found that restrictive practices were mainly experienced negatively by services users, but the use of supportive communication had the potential to mitigate feelings of coercion and increase trust in staff. An interview study with former patients (Study 2) was carried out and the findings reported on the complex relationship between restrictive practices and psychological safety. A working definition of psychological safety was also developed from the findings and refined with the Help from Experts by Experience for Researchers (HEER) group. An interview study with staff working in inpatient mental health services (Study 3) explored the barriers and facilitators to providing psychologically safe care in practice. Finally, a synthesis of former patient’s and staff’s suggestions for providing psychologically safe care in practice was conducted (Study 4) using data from semi-structured interviews carried out in Study 2 and Study 3. This study outlined key areas of mental health care provision that are implicated in providing psychologically safe care. The findings from all four studies have been triangulated and critically discussed to develop seven recommendations for how restrictive practices can be made more psychologically safe for patients in inpatient mental health services. The recommendations and findings from this programme of work demonstrate: 1) the importance of supportive communication to enhance a patient’s trust in staff and psychological safety, 2) the need to empower patients to be active participants in their care and 3) organisations providing safe environments to avoid reliance on restrictive practices.