1 Background

Forensic psychiatry poses many challenges for mental health practitioners, not least in the context of high security hospitals, where balances between care and containment are imperative, yet frequently in contention (Alty and Mason 1994). The uses of coercive measures have been increasingly viewed with controversy over recent years. Indeed questions have been raised as to whether these practices are ethical, moral or indeed necessary at all (Alty and Mason 1994; American Psychiatric Association et al. 2003; Gunn and Taylor 1993; National Mental Health Working Group 2005; NICE 2015; Queensland Government 2008; Soloff 1979; Tardiff 1984). Where coercive measures are used in secure hospitals, healthcare workers are expected to conduct such practices. Juxtapositions are therefore apparent between the roles of healthcare workers as person-centred, recovery-orientated practitioners, in contrast with their roles as agents of security and restriction. Few studies have examined the uses of coercive measures specifically within high security hospitals and even fewer have explored staff experiences of working in this environment (see Chapter 9: The Uses of Coercive Measures in Forensic Psychiatry: A Literature Review). In order to understand the attitudes, cultures and practices within these institutions, it is important to i) explore the processes through which staff decide upon conducting coercive measures, ii) examine workers' thoughts and feelings towards such methods, and iii) consider the implications upon workers as individuals, as well as their roles as mental health practitioners.

2 Methods

This chapter reports on the findings of part of a doctoral thesis, examining staff experiences of conducting coercive measures within Rampton Hospital (Hui 2015). Rampton is one of three high security hospitals, located in the Nottinghamshire countryside. The hospital accommodates approximately 350 patients and is comprised of five directorates, namely, mental health, learning disabilities, personality disorder, dangerous and severe personality disorder and women’s services. The hospital provides the only national high secure hospital provisions for women, patients with learning disabilities and patients who are deaf. The mental health directorate is the largest within the hospital, having 110 beds. It is this directorate in which the interviews were conducted.

During the time of the interviews, the mental health directorate was divided into eight wards; two admission wards, three treatment wards, two pre-discharge wards and one intensive care ward. The study took place on four of the wards (admission, treatment, pre-discharge and intensive care), so that staff experiences could be compared in accordance with the functions of each of the wards and assessments of patients' ‘risks and dangerousness’. Twenty-eight interviews were conducted in total. These were with 9 staff nurses and 11 healthcare assistants, who make up the majority of the hospital’s workforce, along with one ward manager, one team leader, two responsible clinicians, one social worker and one psychologist. The numbers of practitioners interviewed from each of these professional roles were in proportion to those found on each ward. The majority of staff who chose to participate in the interviews were from the intensive care unit (18). This perhaps reflects the higher rates and frequencies of coercive measures being used within this particular ward.

The interviews were conducted using a narrative approach, enabling participants to share their experiences of using coercive measures. Participants were encouraged to talk about their experiences, thoughts and feelings surrounding the uses of restraint, seclusion and segregation within the context of working in a high secure hospital. A semi-structured approach was adopted, using an open-ended style of questioning. Prompts were used to encourage further exploration and understanding. Thus, participants’ thoughts and feelings were made accessible through narratives of the processes of using coercive measures, descriptions of isolated incidents that have stood out for individuals, as well as through sharing personal and professional experiences more broadly.

Throughout the interview process, interview findings were constantly compared and questions framed to deepen the understanding of practitioners’ experiences. Through these comparisons, data were analysed and grouped into themes and further subthemes. Findings indicated that practitioners experienced coercive measures through a series of processes, pertaining to three main themes; (1) decision-making, (2) thoughts and feelings, (3) personal implications and professional implications. These will each be presented and discussed in turn.

3 Results

3.1 Decision-Making

Each of the practitioners spoke of the challenges faced in making, often difficult, decisions to conduct coercive measures. Practitioners spoke of every situation being different, and therefore of the accompanying challenges and difficulties in describing and quantifying specific situations when coercive measures might be used. Decisions to use coercive measures, however, seemed to centre around three main junctures; (1) accountability, (2) safety and (3) having “no other option”.

3.1.1 Accountability

In England, high security hospitals are governed by both the NHS and the Ministry of Justice, a ministerial department of the UK government that has a role in managing and authorising the containment, restriction and discharge of patients under forensic mental health care. The friction resulting from being employed by the NHS whilst remaining answerable to the Ministry of Justice clearly created anxieties amongst staff with regards to their roles and responsibilities:

We are answerable to more people than prisons are, the Home OfficeFootnote 1 and that sort of thing, and people are really wary because you’re answerable, whereas in prison, you serve your sentence and you go, if you reoffend, people aren’t going to be asking questions about the prison officers or wardens, because you will be arrested and you will go back to prison. Whereas here, if people reoffend, questions are asked about us and our practice and what we are doing… we have to answer for those things… it’s not a light thing, it’s a very serious thing (Staff Nurse—male)

[The] legal requirement of your detention, that’s very much driven by the dictates of the Home office and the security practices that the home office tell us that we have to adhere to (Team Leader—male)

The prospect of accountability and levels of responsibility seemingly resulted in conflict between the competing principles of healthcare (NHS) and prison (Home Office) services. Where such conflicts arose, security measures ultimately preceded that of care:

That’s the strange thing, when I first came here, Rampton was its own authority directed under the Home Office. They then got drawn into the Trust, which really tried to put across that the nature of the hospital is care and treatment and then all of a sudden as they’ve tried to do that, you’ve got this massive increase in assessments, risk assessments, big fences, personal alarm systems (Team Leader—male)

The security sometimes governs the nursing, if you know what I mean, so things that you might do in other hospitals, you have to do differently here because of the security measures (Nursing Assistant—male)

As a nurse, when you come to the field of forensics, one of the hardest things that you have to try and balance out is the security aspect of the job that you do, along with the nursing side of how you were trained. It’s something quite different, and the two, I don’t think, ever sit totally comfortably with each other (Team Leader—male)

How you go about putting across your nursing care isn’t always that easy a job within a contained area, a place with massive security practices, but you’ve just got to stay true to yourself (Team Leader—male)

The onus of security appeared not only to be driven by clinicians’ fear and anxieties surrounding accountability but also as a result of their acute sense of responsibilities, particularly surrounding safety. Safety was spoken about through the language of safety, security and protection as will be presented in the following.

3.1.2 Safety

While security aspects of practitioners’ roles seemingly dictate the care they are able to provide, the practitioners spoke of the great levels of responsibility they feel towards maintaining safety. These responsibilities seemed to emerge not only from those governing bodies outside of the hospital, but from protecting patients and colleagues, as well as the public:

You have to bear in mind that we are providing a service to the public and keeping them safe as well… so you’ve got to be very mindful of that, very careful, it’s the reason it’s high secure, the big fences around it is because these people may pose a risk, so while trying to maintain a therapeutic environment for the patients, it’s making sure everybody’s safe as well. Which can be tricky (Nursing Assistant—male)

You come into work every day knowing that there's a chance you might be assaulted or that you might have to restrain a patient... you don't get to Rampton hospital as a psychiatric patient really without having been violent and aggressive in some way or form, so with regard to violence and aggression, we're always aware that there’s a possibility of that (Nursing Assistant—male)

I suppose in a hospital like this you have to cover eventualities… trying to keep people safe, (Nursing Assistant—male)

3.1.3 “No Other Option”

Finally, the decisions of whether or not to employ coercive measures seemed to rest upon whether the risks, or breaches of safety and security, were great enough to warrant such restrictive practices. Practitioners spoke of coercive measures being as used as a last resort when left with no other option:

They’re a last option, it’s something that you’re going to avoid if you can help it because it’s not good for [the] patient is it, you know, it can’t be good for anybody’s mental state, you know, we’re trying to help them get better, it can’t be good for anybody’s mental state (Nursing Assistant—male)

As far as I’m concerned, you know, obviously none of us want that to happen, it’s a last resort so to speak, you know (Staff Nurse—male)

If there’s nothing you can do to calm them down or talk them down or anything like that, then it’s got to be done (Team Leader—male)

We try and avoid it as best we can but sometimes we have no option (Nursing Assistant—male)

Sometimes there is no other alternative. How else do you deal with somebody who wants to stand up in the middle of the day room and fight everybody, you know, I don’t really know another, I can’t really see another option at that time (Nursing Assistant—male)

In exploring the decisions surrounding the use of coercive measures, it became apparent that safety and security are paramount to the ethos of working within a high secure hospital and that clinicians feel under great pressure to maintain a safe environment where they feel both responsible and accountable towards the safety of all patients, colleagues and the public. From the findings presented so far, there is the suggestion of unease surrounding some of the ethos and practices of the high secure environment from clinicians. While accountability, safety and having no other option each contribute towards the decisions made as to whether or not coercive measures are used, they fall short of exploring the thoughts and feelings of practitioners towards conducting such actions. These will be examined in the following sections.

3.2 Thoughts and Feelings Towards the Use of Coercive Measures

The thoughts and feelings of practitioners towards the use of coercive measures appeared to be strongly influenced by their attitudes and philosophies of working within a high secure hospital, as well as towards the patients contained within. The practitioners identified subtle differences in “tolerance” and “boundaries” between members of a team. However, the overarching attitudes were that those contained are patients not prisoners, that the uses of coercive measures are a necessary evil and that where practitioners feel at unease, they tend to mask or manage their feelings through aversion or bravado.

3.2.1 Patients Not Prisoners

Practitioners were adamant and keen to point out that the environment in which they work is ‘a hospital and not a prison’, despite the conflicts and tensions between care and safety regimes being frequently apparent, and in spite of the aforementioned practices of security often preceding that of care:

Even though lots of the nursing staff are members of the Prison Officers Association, that’s their union rather than Unison or something like that…they’re not prison officers, they’re nurses, you know, so the patients are not inmates, they are patients, I think that’s important (Responsible Clinician—male)

We’re nurses, we’re not bouncers, we’re not soldiers, you know, we’re nurses… it’s a very different role, but we’re not prison guards Staff Nurse—male)

I think the thing is with Rampton, you look at prisons and you can sort of think it’s a prison, it isn’t a prison, it’s a hospital and that’s the difference, these people are poorly, you know, and we have to remember that (Staff Nurse—male)

Prisons are supposed to be about rehabilitation… we’re a hospital which means we’re about treatment (Social Worker—female)

3.2.2 “A Necessary Evil”

Of all the practitioners who were interviewed, each person viewed the use of coercive measures as a last resort, secondary to attempts at de-escalating potentially violent situations via verbal means. Practitioners generally voiced negative feelings towards using coercive measures, viewing these as a necessity to prevent injury and to minimise harm, but preferred not to have to undertake these measures as part of their role and duty, given the choice:

It’s not a nice experience but it is a necessary evil (Nursing Assistant—male)

It’s not something that you relish, you know, it’s a needs must, you have to step in for whatever reason to lessen the harm that they’re doing, it’s really for their safety, the safety of the victim that they’re attacking be that another staff or another patient, it’s that part of the job that sometimes is necessary but not that you like, and then you do it to the best of your ability (Team Leader—male)

It’s not something either party enjoys, I don’t think, obviously, you know, it’s an invasion of their privacy, you know, nobody likes it (Nursing Assistant—male)

I think it’s a necessary part of the job, I think it’s a necessary evil. It’s not the most pleasant part of my job but it is so necessary, especially when you’re talking about risk to other people. When you’ve seen violence and experienced violence and been at the receiving end of violence, you would wish somebody to be involved, and manage them, in a safe way, and when people are put at risk, you know, you have to do something… the alternative is not acceptable, it is not acceptable that people can be subject to or victim of violence, not just staff but other patients and there be no consequence and there be no management of that. I’ve seen patients who have been on the receiving end of an unprovoked attack, brutal unprovoked attack, and you have to manage that, you know, you have to manage that. We have a duty of care (Staff Nurse—male)

3.2.3 Banter and Bravado Versus Aversion and Avoidance

Staff support was an important feature identified by practitioners throughout the process of conducting coercive measures. Mutual trust and support were key factors in establishing good team relations and in conducting coercive measures safely. There is an implied sense of dependency between staff, while trust appears to be a major factor in working as part of a team. Indeed, some staff have felt ‘let down’ and angry when colleagues have not responded to incidents in ways that would be expected or have not supported colleagues in a manner felt appropriate. Teamwork, esteem and respect for colleagues were therefore not only associated with levels of training and experience, but also staff willingness to be involved when colleagues are placed in vulnerable situations. Practitioners frequently spoke of the reinforcement of team closeness fostered through camaraderie and banter following serious incidents. Displays of confidence and bravado earned respect between colleagues, whilst those who demonstrated fear and aversion were ostracised through being seen as unreliable, untrustworthy and undependable:

I think it creates stronger bonds between people when you’ve been involved in them sort of incidents together… I mean, I’ve got some friends that are in the army and they say… friends, you know, mates that they’ve made when they’ve been in war zones together, I mean, they say it’s a relationship that other people can’t understand… you know, I suppose it's like that but on a much [less] extreme scale, isn't it? (Nursing Assistant—male)

You've got to support each other otherwise it just wouldn't work, you just wouldn't be able to work with each other (Nursing Assistant—male)

You are conscious of how dangerous it can be and how much you rely on other people to keep you safe, but then again, they rely on you as well (Team Leader—male)

You’ve got to be there for each other (Team Leader—male)

I've seen people with a negative attitude involved in restraint, and it's a very dangerous mix because your personal feelings always come into it, so you always have to be detached about how you feel about it and just do the job in hand, you know, you've got to think about people's safety, the patient's safety, other people's safety, you know, they are paramount (Staff Nurse—male)

I know people, I personally know people that are fearful, fearful of restraint, fearful of that, “Can I?”, and when those incidents happen, they shy away from being involved… some people sometimes develop an aversion, I know quite a few people here that have, and it's not healthy, it's not healthy, you're in the wrong environment to be here to develop an aversion to that (Staff Nurse—male)

The ways in which practitioners act and react towards the uses of coercive measures implies some bearing upon the individual both at a personal and professional level. Whilst so far, the findings have alluded towards collective impacts upon the practitioners as a team, such as through trust, team building and support, the implications of conducting coercive measures upon individual practitioners will be explored in greater detail. A focus will be given towards the influences and interrelations between the practices of coercive measures and practitioners' personal and professional values.

3.3 Personal Implications

Practitioners spoke of the challenges and tensions of working within an institution that “outsiders” know little about and where personal and professional values often conflict. The lack of knowledge and awareness from those outside of the hospital seemingly reinforces an insular community of support and understanding, albeit resulting in feelings of isolation where personal and professional roles and values are misaligned. Clinicians spoke of their inability to tell friends and family about their work, of having to “make peace with” the decisions and actions required of them within a high secure hospital and the challenges faced in attempting to reconcile and consolidate both their personal and professional values so that they could continue working in their roles.

3.3.1 You Can’t Tell People Who Don’t Understand

Practitioners spoke of feeling unable to talk to friends or family who work outside of the institution, since they do not understand:

We are detached from the rest of the world. We're in our own little bubble, so I'm an expert at Rampton but out there I'm a novice, I wouldn't know, I wouldn't cope out there, but in here I'm an expert, but out there… no (SN - male)

You can’t really tell people that don’t understand, so you can’t take it home with you, because they don’t understand the process, they don’t understand the things that you’re going through and that you’re dealing with (Staff Nurse—male)

I think it's something that only people that work here can understand (Nursing Assistant—male)

3.3.2 Peace and Reconciliation

Clinicians described a sudden lull in their emotions, following the heightened tensions in managing incidents, such that staff require time to manage their own emotions before continuing with their usual work. The outlet of emotions associated with the challenges of working within a high secure hospital were described by clinicians as ‘making peace with’ their personal and professional roles and identities:

You’re working with people at the end of the day, you’re dealing with people. Patients are people and it’s violent at the worst, it’s a violent act, it’s a violent process and you have to wade through the mist, the red mist and process it, and do things professionally and all of those things. The adrenaline’s going, you know, your senses are heightened and then afterwards you almost crash, you know, yeah, you almost crash (Staff Nurse—male)

What always plays on your mind is just to make sure you are doing things right, you know, it's a volatile situation whereby emotions are running high, up and down, but still as staff, you just keep on reminding yourself that, you know what, you have to do things right (Staff Nurse—female)

Everybody is a little bit pumped up, so there is almost a little bit of post seclusion sort of, not blues, but phew, that was phew, what happened then, but then you sort of take off, evaluate it (Nursing Assistant—male)

You have to deal with the fear, you know, fear sets in and it’s fear of there being another incident, what if the worst incident, what if I can’t help, what if, you know, could I have got there quicker… you’re working with, you’re dealing with those things, those thoughts of could I have got there quicker, what if, what if, I should have got there quicker, you know, what could I have done, I should have been more attentive and all those sorts of things, you know, and it’s what ifs that you’re dealing with, and that sense that you’ve let somebody down… the fear of should it happen again, can I be relied upon, am I dependable, you know, am I good at this and all that kind of stuff, so it’s a range of things you’re battling and dealing with… I remember for weeks, carrying this, you know, and you have to make your peace with it, I tried my best, I did my best, there was nothing more I could have done, you know (Staff Nurse—male)

3.3.3 Consolidating Personal and Professional Values

Practitioners describe their attitudes and outlooks as having to change in order to manage and accommodate the institutional and emotional demands of their working environment and the coercive practices they are called upon to conduct:

I found my attitude towards it changed, when I experienced it first-hand, when I witnessed it first-hand, my attitude towards it, the necessity of it changed...It’s not easy when you see it for the first time, and then when you see violence against staff, you know, people that you work with, colleagues, friends, especially some of the attacks I’ve seen, quite brutal attacks on staff, that can be quite disturbing. You have to contend with that, you’ve got to put it in the right context and you have to process and deal with it (Staff Nurse—male)

It’s not the easiest of jobs, sometimes, it’s very difficult to, when you have to be physically involved in restraining patients, that doesn’t initially sit very easily with how you’re first educated to what nursing is, it doesn’t, you know, they don’t sit comfortably together (Team Leader—male)

I think you’ve got to sort of, you’ve got to stay true to yourself as to what brought you into nursing and then how you go about putting across your nursing care isn’t always that easy a job within a contained area, a place with massive security practices, but you’ve just got to stay true to yourself (Team Leader—male)

Through examining workers' experiences of working in a high secure hospital, the tensions between organisational expectations, professional practices and personal values become apparent. These will be considered with a specific focus upon the uses of coercive measures.

3.4 Implications for Practice

The implications of using coercive measures upon workers' roles and practices were discussed as a sequence of processes related to 1) preparedness, 2) confidence and 3) routine. Practitioners spoke of their anxieties of conducting coercive measures for the first time, the confidence they feel in knowing what to expect and finally, confidence in their capabilities of conducting coercive measures. The paradox of becoming confident in their every day practices, however, were the rituals, routines and emotional detachments towards such practices over time. The processes of becoming institutionally embedded and emotionally detached will therefore be explored in the following.

3.4.1 Nothing Prepares You

Frequent distinctions were made between training, on the one hand, and the intensity of experiencing and enacting approved holds within the ward environment during actual incidents on the other. Staff attributed these distinctions, in part, to the lack of resistance that staff put up against their colleagues during training, as well as to the speed, intensity and potential for injury with which real-life incidents occur:

It’s nothing the same at all, it’s nowhere near… when you’re practicing, you’re just practicing with each other and nobody ever puts up any resistance or anything, so you’ve got time to do it all properly whereas in a restraint, a patient never stands there and lets you grab them, they’re trying to fight you, so it’s totally, totally different, totally different… most of the time, you just have to do it, you just have to try and do what you’re trained to do, and just do it as quickly as you can but you haven’t got time to think about it… if a patient comes at you swinging his arms and trying to punch you, you just have to, you can’t think, hang on a minute, I need to put my hands there, you just get on with it (Nursing Assistant—male)

In a way, what you’re taught down there is never the same, you never get the reality of it, there’s no, because nobody really struggles when you’re doing the training, if you do the shield training that’s slightly different because when you do the shield training, the instructor’s there, they really make you have it, they do, metal batons and baseball bats and it’s quite difficult, it is, quite scary as well when they’re whacking you with a baseball bat on a plastic shield (Nursing Assistant—male)

You can talk about approved holds and how you should take people, but when limbs are flying everywhere and people are scrapping or somebody’s just been hit and they’ve hit the floor, especially if the patient’s putting up a struggle, sometimes it’s just grabbing onto something and holding it still and when everything’s stopped moving, then, one at a time, get them into the appropriate holds (Staff Nurse—female)

3.4.2 Confidence and/or Desensitisation?

Practitioners spoke of the challenges in not knowing how they might react when initially faced with an incident requiring the use of coercive measures. They often spoke of the relief they felt after experiencing their first encounter of using coercive measures, of knowing what to expect and having an increased confidence in their abilities. These experiences, however, were frequently coupled with detachment and desensitisation in coping with the traumas of witnessing and managing such situations:

Once you’ve done the first one, it’s kind of a relief, you know, the procedure, if anything, it makes you feel more confident (Nursing Assistant—male)

You have to get to a point where you get over it because the next one is just going to be the same again (Staff Nurse—male)

I think with time, you get used to it, you get used to it (Staff Nurse—female)

3.4.3 Rituals and Routines

In managing and coping with both personal and professional values, staff regularly refer to individual rituals that they undertake in preparing themselves for working within the high secure hospital organisation. The routines and rituals that staff identify are seemingly associated with detaching themselves from the patients that they work with, the crimes they have committed and the personal judgements that staff hold in relation to each of these:

It’s another hat that I’ve got on, that I have to wear when I come to work so I can put all my morals, or most of my morals and beliefs to one side and in a box because I have to put my work hat on, which means that I have to deal with these patients and I know that patients come to Rampton because they’ve done horrendous offences (Staff Nurse—male)

You learn to deal with situations and not let them affect you… if a patient died in hospital, I’ve got no love, feelings or emotions for that person, so it’s easier for me to do all those things (Staff Nurse—male)

You have to put all that sort of stuff in a box, I’m not saying it’s easy or that it doesn’t affect you or anything… it is hard, I think you just have to be aware of it and try and manage it to the best of your capabilities whether it be through supported supervision or, you know, it’s not easy (Staff Nurse—male)

3.4.4 It’s Just a Job

Coupled with, and related to, practitioners' routinising of their actions, were their descriptions of using coercive measures as simply being “part of their job”. This distinction and separation of their personal values from that of their work perhaps indicates degrees of detachment with the actions that they feel most uncomfortable with conducting, thus shifting the responsibility onto their role, rather than themselves as individuals:

You do kind of get used to it, it is part of the job, you don’t enjoy it but you know it’s there and you deal with it, try and make a bit of light of it afterwards, as a coping mechanism more than anything (Nursing Assistant—male)

It’s just my job, I’m not here to criticise, society needs somewhere to put people who have done this and I just work in that environment (Nursing Assistant—male)

A lot of the time it’s just part of the job and you respond to what you need to do at the time, so apart from the particularly violent ones or ones that are completely out of the ordinary, it just gets to be one of those things, you just do it (Staff Nurse—female)

I think you have to remind yourself that you’re here to do a job and you have to do the best job (Social Worker—female)

4 Discussion and Conclusions

From examining findings from the interviews, several key themes emerge. First, the decisions made surrounding the uses of coercive measures were greatly influenced by workers' perceptions of accountability, responsibility and assessments of risk and safety in the workplace. Second, inherent in these decisions and actions were practitioners' thoughts, feelings and personal values. These were articulated in relation to the uses of coercive measures, the patients accommodated within high secure hospitals, their roles as healthcare professionals and the secure environments in which they work. Third, the processes by which staff negotiate their personal values, professional roles and organisational expectations are particularly noteworthy in gaining greater understandings of practitioners’ experiences of working in this environment.

Each of the practitioners were adament that although working in a high secure environment, their roles were of healthcare and those they work with are patients, not prisoners. However, discrepancies were revealed between the language used and the security and containment measures practiced wthin. Workers within forensic hospitals are accountable to both healthcare and legal governing bodies. These dual obligations frequently place workers in contention with their personal values and professional roles.

Findings from the interviews alluded to the marginalisation of those who have an aversion to conducting coercive measures. To avoid such marginalisation, workers tend to adopt a mask of confidence and bravado in order to be accepted by others, whilst displaying an appearance of coping. Workers' feelings towards their work seemingly resulted in either (1) clinicians taking ownership of their fears and anxieties at the expense of being outcast by their colleagues or (2) masking their fears and anxieties through banter and bravado in the hope of being accepted. Each of these rely on elements of deception, either towards the self or others, both of which are considered unhealthy responses, with the potential for toxic consequences as practitioners become increasingly detached and isolated (Hochschild 1983).

The interviews with practitioners uncovered their changing emotions towards their work through a series of processes: from the fear and anxieties of anticipating their first experiences of conducting coercive measures to gaining confidence and eventually routinising such actions as being “part of their job”. Each of these experiences contributed to the clinicians’ detachment from their work, perhaps as coping strategies in shielding themselves from the uncomfortable situations they are tasked with managing. These processes may have profound implications not only for the individual practitioners involved but also in terms of care delivery. Studies have previously found that clinicians develop “fear and abjection” towards patients within secure settings and thus view patients as objects rather than people (Jacob et al. 2009; 2011a & 2011b). This raises important questions as to 1) the quality of care being delivered under such circumstances, 2) how such negative cycles of detachment and objectivised care can be broken and 3) whether it is possible to provide humanistic, person-centred, recovery-orientated care within these challenging environments and conditions. These questions are particularly important given the conflicts between the values and practices of healthcare workers and in light of the national and international guidelines towards the reduction of coercive measures.

Such revelations lead to questions of how clinicians can be supported through these challenges, how such support might be accessed without fear of judgment from fellow colleagues, and, moreover, how cultures of openness and honesty can be fostered within environments where circles of fear often lead to masking, aversion and feelings of isolation. These questions and associated answers may be key to preventing staff fatigue, improving the retention of staff working in these environments, while encouraging cultures of support in place of fear and apprehension. Workers must learn to look after themselves by changing the internal cultures of secure environments, by supporting colleagues to take ownership of their fears, anxieties and apprehensions and by extending this approach towards those in their care. Through such changes, emotional isolation may be replaced with acceptance and emphases on containment replaced with care.