Authors' objectives: 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. 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. The Department of Health and Social Care estimate that between 25% and 50% of all acute hospital admissions are patients who are also living with dementia, making them one of the largest patient populations by diagnostic category. PLWD are also a highly vulnerable group within the hospital, at increased risk of deterioration, physical and cognitive decline, avoidable harm and adverse outcomes, including delayed discharge and institutionalisation. Recent UK government enquiries and reports have repeatedly identified institutional cultures of restrictive practices (containment, restriction and restraint) as key features of the care inequalities PLWD experience during a hospital admission. To date, no UK research has systematically examined the use of restrictive practices, the forms it takes, rationales for its use, and its impacts on PLWD, carers and staff within NHS hospital wards. While there is a range of guidance across the NHS to inform its use for other patient populations and care settings, there are no best practice guidelines for its appropriate use, or training to support acute staff in using alternative approaches in the care of patients admitted with a diagnosis of dementia. Our public consultations identified that use of restrictive practices in hospitals as a pressing research priority and PLWD coproduced this research. Many have direct experience of these practices in their care. In response, this in-depth ethnographic study examined the everyday cultures of restrictive practices in the care of PLWD during a hospital admission, exploring what forms these practices take, the rationales for their use, and the experience of these practices from the perspectives of PLWD, their families and ward staff. With a goal to identify evidence-based (and alternative) strategies in the care of PLWD that are achievable, safe and transferrable across care settings. Our objectives were to: Provide a detailed examination of the social and organisational context in influencing the everyday care of PLWD to understand the (a) nature of restrictive (and alternative) practices within wards, (b) circumstances and contexts of use, (c) care practices when PLWD are perceived as at risk, or when their behaviour is perceived as ‘challenging’, ‘disruptive’ or ‘aggressive’. Examine the recognition, understandings and experiences of restrictive (and alternative) practices during an admission from the perspectives of PLWD and their families. Examine staff perspectives (a) their understandings and recognition of restrictive practices, (b) the formal frameworks and informal rationales drawn on to inform the care of PLWD. Translate the findings into evidence-based strategies to support best practice and alternative approaches to feasibly improve the care of PLWD at ward level.

Authors' results and conclusions: 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. 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. Analysis of data provides understandings of the complex social and organisational interactions that occur in these settings, revealing how the everyday use of restrictive practices occurs in a complex set of wider institutional relations, expectations and priorities with consequences for PLWD admitted to these settings. For purposes of this report and considering the scope of the study, our analysis revealed eight themes: (1) everyday routine use of restrictive practice; (2) cultures of containment; (3) patterns of intensification and ‘tightening’; (4) low tolerance of risk; (5) deprivation of liberty and everyday rights; (6) legal frameworks; (7) the impacts and consequences of the use of restrictive practices in the care of PLWD and (8) good practice and de-escalation. The nature of restrictive practice We identified the use of restrictive practice in the care of PLWD was an embedded aspect of everyday routine ward care, within all shifts observed within the acute wards, regardless of the ward, time of the day and day of the week. The restrictive practices used within these ward settings took a wide range of forms, with use of raised bedside rails, ward furniture and verbal commands, the most frequently used. These practices were typically carried out swiftly, and at pace, to contain and restrict the movements of PLWD at the bedside. What is of significance is that their use was embedded within timetabled care and viewed by staff as routine; thus, these forms of restrictive practices were typically unrecognised and unrecorded. We identified that ward staff found defining and identifying what constituted restrictive interventions in their routine practices as challenging. Our findings demonstrate that, while there was significant variation between sites in the types of restrictive practice most commonly employed and the use of legal frameworks within them, cultures of containment were in operation in the care of PLWD across these settings. Containment (in bed, at the bedside, within the bay) was both a requirement and expectation as part of the organisation and delivery of care. Any challenge to containment was met with restrictive practice, starting with raised bedside bars, placement of furniture, supervision, and escalating should the person continue to challenge containment practices. These cultures were driven by genuine staff fears over personal and professional reprisals, and enabled by a culture in which family visitors, volunteers and engagement have disappeared from ward settings, creating challenging environments of ennui and isolation.

Authors' methods: 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. 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. One hundred and sixty-eight individuals consented to participate directly in this study, also contributing to 1116 ethnographic interviews. 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. This ethnographic study drew on symbolic interactionist traditions to provide a detailed contextual interpretive understanding of the social world of the ward. This supported a detailed examination of how the organisational processes influence social actors within them to work in particular ways when caring for PLWD. It also allowed us to examine taken-for-granted practices that have over time become part of the everyday ward cultures and the consequences of these ways of working PLWD. This study was carried out across nine NHS hospital wards (six acute and three specialist mental health settings) within six NHS trusts (working in dyads in three towns and cities) across England. Sites were purposefully selected to represent a variety of hospital types, geographical locations and socioeconomic catchments (we were not able to access proposed sites in Wales). We conducted 225 days of ethnographic observation fieldwork within general acute medical wards, Medical Assessment Units (and variants thereof), older people's medicine wards and specialist mental health settings. Overall, we collected approximately 500,000 words of observational fieldnotes, transcribed, cleaned and anonymised by the research team. To obtain contextual understanding of the events and practices with these settings, we conducted 1116 in-depth in situ interviews with healthcare professionals, PLWD and care partners. Research Ethics Committee (REC) approval for the study was granted by the NHS Research Ethics Service via the London – Bromley REC (22/LO/0448) and given approval by the Health Research Authority on 15 July 2022 [Integrated Research Application System (IRAS) 313618]. The research project was approved for the purposes of the Mental Capacity Act 2005 (section 31).

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/NIHR132903

Year Published: 2026

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/GJKF0714

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/GJKF0714

Organisation Name: NIHR Health Services and Delivery Research programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk