I am a small person. I belong to a culture that values contact sport, reflected in the Rugby World Cup victory by the New Zealand All Blacks in 2015. I was actively engaged in this sport from the age of 5 years up until my late teens playing with boys and young men often twice my size. When confronted with force, I had no alternative but to use my brains rather than brawn. I quickly became adept in anticipating flash points and circumventing them through cunning rather than confrontation.

It did surprise me when I first commenced forensic mental health nursing (over 20 years ago) that the use of force was far too often used to manage distress, arousal, and anger. The use of "restrictive interventions" (seclusion, physical restraint, and mechanical restraint) is still legally mandated in certain situations. Such practices have always seemed an anathema to me, a contradiction to ethical principles of autonomy, beneficence, and nonmaleficence. Yet, the workplace culture has traditionally supported the use of restrictive interventions in managing perceived risk of harm to self or others. It has been far too easy to be sucked into this culture. I have been part of such practices, yet my fondest memories of forensic mental health nursing involve preventing the use of restrictive interventions altogether. I can recall being with service users experiencing arousal and aggression. Sometimes, the volatility was uncomfortable for me as a clinician. However, a focus on allowing people to express themselves or using a calm focused approach to communicate with people was all that was needed to defuse the arousal.

Twenty years on and we are in a new epoch. There is an international drive to reduce and, in some cases, eliminate the use of restrictive interventions. The reasons for this momentum are obvious. Restrictive interventions in mental health service delivery are coercive violations of service users' human rights. There is substantial evidence that highlights that the use of restrictive interventions has negative consequences for service users, their families, and clinicians. Restrictive interventions compromise the therapeutic relationship, cause physical harm, can be experienced as traumatic events, and may recapitulate previous experiences of trauma. The United Nations Convention on the Rights of Persons with Disabilities (specifically Article 15; United Nations, 2006) set the scene for this reduction. Many jurisdictions have followed suit in developing government policy and mental health legislation aligning with the reduction and, in some cases, elimination of restrictive interventions.

However, despite specific government and policy level "top-down" approaches that require mental health services to reduce incidences of restrictive interventions, the evidence of positive change in this regard is limited. Studies have published data showing improvements in reducing the frequency of the use of restrictive interventions, reducing the duration of their use, and decreasing the number of repeat episodes used on individual service users during the course of their engagement with acute mental health services (e.g., Happell & Gaskin, 2011). However, these improvements have tended to be delimited to single hospital settings. So-called "large-data" sets comprising restrictive intervention data for entire jurisdictions are scarce, and the absence of such data makes it difficult to ascertain if the efforts to reduce the use of restrictive interventions have truly resulted in appreciable change. Although there have been efforts to standardize epidemiological measures of the use of restrictive interventions, there remains a lack of heterogeneity across organizations, regions, and countries in the reporting of data, which makes comparisons difficult.

From the "large data" analyses that do exist, there appears to be marked variations across countries in the frequency of the use of restrictive interventions. If we consider the use of seclusion, for instance, there are countries where seclusion is not used at all and those in which it is frequently used. Within countries, there are marked sociodemographic variations. For instance, in New Zealand, the use of seclusion with Maori (the indigenous people of this country) far exceeds that of the non-Maori population and is the highest population-based seclusion rate reported internationally (McLeod et al., 2013). However, although these variations are signaled, the reasons for them are poorly understood.

Although "big picture" change remains unclear, the momentum toward the reduction in the use of restrictive interventions has moved through to service delivery and nursing practice in particular. The Safewards model and its interventions provide evidence of nursing care that prevents the use of restrictive interventions. At the heart of the Safewards interventions are the use of effective communication skills and the investment of time to really know and understand those people whom we serve. These inherent person-centered approaches to care reduce conflict and containment and generally make acute mental health inpatient units more pleasant places for people to recover in, for staff to work in, and for families to visit (Bowers et al., 2015).

There is also evidence for a systemic service-based approach to reducing the use of restrictive interventions. The "six core strategies" target improving the leadership that drives organizational change, using data to inform practice, focusing on workforce development, using seclusion and restraint prevention interventions such as sensory modulation and trauma informed care, employing the expertise of people with lived experience of mental illness to work alongside clinical staff, and using debriefing techniques when restrictive interventions occur to create understanding and avert the use of restrictive interventions in the future (Huckshorn, 2006).

Yet, as nurses gradually endorse such culture shifts, further challenges in the use of restrictive interventions are arising. I recently worked in a nurse academic position in Victoria, Australia. I was horrified to hear nurses in the emergency departments referring to the practice of using "shackles." This pejorative expression actually refers to the use of mechanical restraints (devices used to limit the movement of service users). People who experience mental health crisis in the community in Victoria are often transported by police to public hospital emergency departments. Behaviors that are perceived by staff as problematic in the emergency department are either managed by security staff or nurses who commonly use restrictive interventions (especially physical restraint and mechanical restraint). Much is also written about people presenting to health services under the influence of methamphetamine. There is a known association between the use of this recreational drug (especially in its crystallized form) and aggression. There is an anecdotal indication of the increased use of restrictive interventions to manage this aggression, in both emergency departments and acute mental health inpatient services.

Despite these challenges, there is a serious focus on the reduction and, in some cases, elimination of restrictive interventions in mental health services, with hopefully our colleagues coming on board from other services where these restrictive interventions occur. We are making progress. However, restrictive interventions continue to be used as a last resort in the management of risk of harm to self and others. Situations still arise when distasteful and forceful actions are deemed necessary. We cannot afford to be blase in our response to such situations. Critical reflection involving debriefing with the service user concerned is required to understand what has occurred and avert the use of restrictive interventions in similar situations in the future.

We are gradually creating a better understanding of the use of restrictive interventions and are aware of evidence-based nursing practice which prevents their use. It is now up to us, as nurses, to drive practice change. To quote the words of the Dalai Lama: "Each individual has a universal responsibility to shape institutions to serve human needs."

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