Mental health nursing’s dirty work

Yesterday the national mental health charity Mind released information on the use of face-down restraint in mental health services. It says:

Mind is today calling for the government and NHS England to put an end to life-threatening face down restraint of people with mental health problems in healthcare settings. Data secured by Mind under the Freedom of Information Act reveals that at least 3,439 patients in England were restrained in a face down position in 2011-12, despite the increased risk of death from this kind of restraint.

Restraining people is part of mental health nursing’s ‘dirty work’. This is a phrase which originally comes from the American sociologist Everett Hughes. Robert Emerson and Melvin Pollner picked it up in a paper titled, Dirty work designations: their features and consequences in a psychiatric setting, and more recently Paul Godin wrote about A dirty business: caring for people who are a nuisance or a danger. There are plenty of other ‘dirty work’ articles out there, too, for those interested in finding them.

‘Dirty work’ involves doings things which are in some way tainted or shameful, but which might still have to be done. A professional group’s dirty work is not the first thing its members typically like to talk about when asked to describe what they do. When mental health nurses present themselves to others it is the helping relationships they build, the listening they do and the recovery they promote that are more likely to feature. My guess is that experiences of holding, secluding and forcibly medicating people are not things that nurses immediately volunteer.

Because dirty work can sometimes feel degrading and morally suspect it can feel easier not to talk about it at all. The good news in mental health nursing is that there are plenty of people interested in describing, researching and questioning the more coercive and controlling aspects of what we collectively do. Len Bowers and Joy Duxbury are examples. In addition to calling for a ban on face-down restraint, in its news release yesterday Mind pressed for the implementation of national standards and accredited training in this area. Nurses have a big part to play in the debates which are to follow and in developing new practices, and I’ll be watching with interest.


4 thoughts on “Mental health nursing’s dirty work

  1. Great post Ben. i recall many years ago some thought that the advent of supervised discharge would lead to restraint being used in the community by nurses. Appalling I know but perhaps it also shows that you can never be sure precisely how policy and guidance will be interpreted at local level. I think MIND have done a great job in getting this issue into the media today. For mental health nurse academics there are important questions, who is teaching restraint procedures and what is the evidence base for this teaching? From a research perspective we need to know what current practice actually is because we can surmise that it varies significantly from prescribed procedures and perhaps too from place to place. I think too we need more evidence and emphasis on de-escalation and wonder if staff numbers and staff mix has a significant effect on decisions to restrain or situations escalating towards restraint? Not my area at all but it is an important one for mental health nurses and of course people who use services who seem to be poorly heard.

    1. Good questions, Michael: reinforcing the importance of Mind’s call for national standards (for education as well as practice). I’m wondering if Len Bowers has data on the relationships between staffing and restraint levels? The information Mind has obtained shows enormous differences in the use of face-down restraint across NHS organisations, so I’m also thinking about local contextual features having a bearing on what happens.

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