Northcott, Andy ORCID: https://orcid.org/0000-0003-3030-9861, Featherstone, Katie, Mwale, Shadreck ORCID: https://orcid.org/0000-0002-5773-8458 and Wyatt, Megan (2026) The use of restrictive practices in the everyday care of people living with dementia in hospital settings: an ethnographic study. Health and Social Care Delivery Research, 14 (7).

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Abstract

Abstract

Background: Inquiries, National Health Service serious incident reviews and media reports identify people living with dementia at significant risk of experiencing restrictive practices during an unscheduled acute hospital admission. However, to date, this has not been the true focus of substantive empirical research.

Objectives: To explore the use of restrictive practices in the care of people living with dementia during an unscheduled acute hospital admission. To identify evidence-based (and alternative) strategies in the care of people living with dementia that are achievable, safe and transferrable.

Design: An ethnographic study (observation, ethnographic interviews, documentary analysis) in the symbolic interactionist research tradition, with the goal to deliver an in-depth empirically driven analysis of everyday acute care.
Setting: This ethnography was carried out for 225 days over an 18-month period between 2023 and 2024. In total, nine wards were observed across six National Health Service trusts in England, covering six acute wards (assessment and older peoples care) and three mental health wards (specialist older people mental health). Sites were chosen for diversity of demographic, geographic and practice variables.

Participants: One hundred and sixty-eight individuals consented to participate directly in this study, also contributing to 1116 ethnographic interviews.

Results: Our analysis identified a culture of containment within acute wards. The use of restrictive practice in the care of people living with dementia was an embedded aspect of routine ward care, within all shifts observed within acute wards, regardless of the ward, time of day and day of the week. Raised bedside rails, ward furniture and verbal commands were most frequently used, often quickly escalating to the use of enhanced observation, typically carried out at pace, to contain and restrict movement to the bedside. Recordable methods included the use of physical force and sedation. Our analysis demonstrates these apparently diverse range of practices cannot be understood in isolation but were utilised multiply in the care of individuals and cohorts of people living with dementia. Because their use was embedded within timetabled care, ward staff found defining and identifying restrictive interventions in their routine practices challenging, meaning these forms of restrictive practices were typically unrecognised and unrecorded. Staff experienced significant emotional impacts from using restrictive practices in patient care. We identified a range of practices to support the reduction of restrictive practice within the acute setting. These included engagement with people living with dementia, making full use of the activity resources available to the ward, and supporting people living with dementia to leave the bedside to walk within their bay or ward.

Limitations: The potential for the Hawthorne effect was considered within the study design with the duration of the observation period within each ward designed to minimise this. Post-admission follow-up interviews with people living with dementia and their family partners were not possible due to low number of family visitors across all ward settings during the observation period.

Conclusions: Cultures of containment were embedded within routine organisation and delivery of care within acute wards, viewed as necessary for care delivery, required to increase patient safety, minimise risk of falls, absconding, or violence. Staff felt unable to practise in other ways for fear of risks to people living with dementia and reprisal. De-escalation approaches to reduce distress, as observed in appropriately resourced specialist units, are recommended
over containment.

Future work: Development and translation of findings into open access training and National Health Service organisational tools to support best practice and alternative approaches in the care of people living with dementia at ward level will be coproduced in collaboration with our patient and public involvement participants, Improvement Cymru, and Dementia UK.

Study registration: This study is registered as ISRCTN11797465.

Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR132903) and is published in full in Health and Social Care Delivery Research; Vol. 14, No. X. See the NIHR Funding and Awards website for further award information.

Item Type:	Article
Identifier:	10.3310/GJKF0714
Date Deposited:	19 Mar 2026
URI:	https://repository.uwl.ac.uk/id/eprint/14749
Sustainable Development Goals:	Goal 10: Reduced Inequalities

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