Restraint and seclusion: a review of the literature

Nurses' attitudes to the use of seclusion: a review of the literature

Seclusion is now widely recognized as a coercive strategy with negative consequences for the consumers and staff involved. Nevertheless, this intervention continues to be used frequently in mental health services internationally. Due to their direct care role, nurses are commonly involved in the initiation or management of seclusion. Understanding nurses' attitudes to seclusion is therefore essential for the success of any attempts to reduce its use. A review of the literature was conducted using the search terms 'patient', 'seclusion', 'attitudes', 'nurses' and 'containment'. Twenty-eight articles which met the inclusion criteria were identified. Analysis of these articles identified six main themes: a necessary intervention; workplace culture; staff composition and experience; conflict; ethical considerations; and consumer characteristics. An overview of the literature is presented according to these main themes. The research suggests that most nurses support the continued use of seclusion as a strategy for the management of violence and aggression. A deeper understanding of the factors that influence attitudes is necessary if seclusion rates are to be effectively reduced.

A review of interventions to reduce mechanical restraint and seclusion among adult psychiatric inpatients

This review examines the nature and effectiveness of interventions to reduce the use of mechanical restraint and seclusion among adult psychiatric inpatients. Thirty-six post-1960 empirical studies were identified. The interventions were diverse, but commonly included new restraint or seclusion policies, staffing changes, staff training, case review procedures, or crisis management initiatives. Most studies reported reduced levels of mechanical restraint and/or seclusion, but the standard of evidence was poor. The research did not address which programme components were most successful. More attention should be paid to understanding how interventions work, particularly from the perspective of nursing staff, an issue that is largely overlooked.

Errorless Compliance Training to Reduce Extreme Conduct Problems and Intrusive Control Strategies in Home and School Settings

The present case study involved intervention for a 7-year-old boy with a history of extreme aggression and noncompliance. Given the severity of his behavioral difficulties, his parents used highly coercive consequences, including physical restraint, which significantly compromised the parent—child relationship. The authors used errorless compliance training, a success-based, noncoercive intervention strategy to assist the mother in obtaining child cooperation without need for physical intervention. Although initial intervention attempts were ineffective because of the poor quality of the mother—child bond, systematic adjustments to the intervention eventually produced substantial improvements in child compliance in the home. Concurrent use of the intervention in the child’s classroom led to meaningful gains in classroom compliance. Anecdotal reports from the mother after intervention suggested widespread improvements in prosocial behavior and the parent—child relationship. The study findings provided support for use of errorless compliance training as a home and school-based alternative to interventions that require punitive or coercive consequences to suppress severe antisocial behavior.

Prediction of aggression and restraint in child inpatient units

OBJECTIVE

The aim of the present exploratory study was to determine the predictors of aggression and restraint in children admitted to a child psychiatric inpatient unit in Melbourne, Australia.

METHOD

A retrospective review of incident report forms over a 12 month period at the State Wide Child Inpatient Unit (SWCIU) was conducted. These report forms were based upon 41 children aged 5-12 years, who had various psychiatric diagnoses including conduct disorder, attention-deficit-hyperactivity disorder and anxiety disorders.

RESULTS

A total of 70 children were admitted to the SWCIU during the audit period. Forty-one children aged 5-12 engaged in 235 violent incidents. A high-risk assessment and disruptive behaviour disorder were associated with aggressive behaviour and restraint. Disruptive behaviour disorder also predicted more serious episodes of aggression.

CONCLUSIONS

There are readily identifiable patient factors that predict aggression and the need for restraint in child inpatient units.

The reasons for using restraint and seclusion in psychiatric inpatient care: A nationwide 15-year study

BACKGROUND

The containment or the prevention of actual violence is the primary justification for the use of restraint and seclusion in psychiatry. The aim of the present study was to determine the grounds for using restraint and seclusion in clinical practice in Finland, and whether these reasons have changed over a 15-year period as a result of legislative changes.

METHOD

A structured postal survey concerning the reasons for restraint and seclusion was completed in all the Finnish psychiatric hospitals during a predetermined week in 1990, 1991, 1994, 1998 and 2004. The duration of the episode as well as demographic and clinical information on the restrained and secluded patient were also reported.

RESULTS

Agitation/disorientation was the most frequent reason for the use of restraint and seclusion. The duration of the restraint and seclusion episodes was not determined by the reason for using these measures. Some differences in the reasons were found among subgroups of patients.

CONCLUSION

Clinical practice deviates from the theoretical and legal grounds established for restraint and seclusion, and is too open to subjective assessment and interpretations.

Case study evaluating the impact of de-escalation and physical intervention training

Violence and aggression is acknowledged as a serious issue in the mental health services. The aims are to explore whether de-escalation and physical intervention training is effective in reducing incidents and incident severity on a Psychiatric Intensive Care Unit (PICU) and to consider the cost impact. Poisson regression analysis was used to compare the number and severity of incidents on a PICU before and after de-escalation and restraint training. This study shows no significant differences in the number or severity of incidents before and after training. Objective assessment in the evaluation of interventions to improve the safety of the inpatient services is difficult when data is recorded inconsistently or inaccurately. The severity of incidents needs to be defined more fully to allow accurate measurement of the efficiency of techniques employed to resolve violence. The cost impact of training in the management of violence in relation to the benefits remains unclear in the absence of accurate data being recorded.

"Coercion Experience Scale" (CES)--validation of a questionnaire on coercive measures

BACKGROUND

Although the authors of a Cochrane Review on seclusion and mechanical restraint concluded that "there is a surprising and shocking lack of published trials" on coercive interventions in psychiatry, there are only few instruments that can be applied in trials. Furthermore, as main outcome variable safety, psychopathological symptoms, and duration of an intervention cannot meet the demand to indicate subjective suffering and impact relevant to posttraumatic stress syndromes. An instrument used in controlled trials should assess the patients' subjective experiences, needs to be applicable to more than one intervention in order to compare different coercive measures and has to account for the specific psychiatric context.

METHODS

The primary version of the questionnaire comprised 44 items, nine items on restrictions to human rights, developed on a clinical basis, and 35 items on stressors, derived from patients' comments during the pilot phase of the study. An exploratory factor analysis (EFA) using principal axis factoring (PAF) was carried out. The resulting factors were orthogonally rotated via VARIMAX procedure. Items with factor loadings less than .50 were eliminated. The reliability of the subscales was assessed by calculating Cronbach.

RESULTS

Data of 102 patients was analysed. The analysis yielded six factors which were entitled "Humiliation", "Physical adverse effects", "Separation", "Negative environment", "Fear" and "Coercion". These six factors explained 54.5% of the total variance. Cronbach alpha ranged from .67 to .93, which can be interpreted as a high internal consistency. Convergent and discriminant validity yielded both highly significant results (r = .79, p < .001, resp. r = .38, p < .001).

CONCLUSIONS

The "Coercion Experience Scale" is an instrument to measure the psychological impact during psychiatric coercive interventions. Its psychometric properties showed satisfying reliability and validity. For purposes of research it can be used to compare different coercive interventions. In clinical practice it can be used as a screening instrument for patients who need support after coercive interventions to prevent consequences from traumatic experiences. Further research is needed to identify possible diagnostic, therapeutic or prognostic implications of the total score and the different subscales.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN70589121.

Mental health service users' perceptions and experiences of sedation, seclusion and restraint

BACKGROUND

Sedation, seclusion or restraint are recognized methods of containing a person experiencing an acute psychotic episode with behavioural disturbance which has not responded to verbal or non-sedating pharmacological interventions. These interventions pose significant ethical and practical challenges to service providers who are responsible for safeguarding the human rights of mental health service users.

AIMS

In a collaborative two-phase study between mental health care providers and mental health service users, the perceptions and experiences of a group of service users who have been exposed to sedation, seclusion and restraint were explored.

METHOD

A focus group was conducted with eight service users. The content of the focus group was transcribed and themes were identified using thematic analysis. These were presented to a second focus group consisting of eight other service users for validation and comment. Based on the results of the focus groups, a questionnaire was developed and administered to a convenience sample of 43 service users in three localities.

RESULTS

Service users reported inadequate communication between them and service providers and perceived that their human rights had been infringed during acute episodes of illness.

METHODS

of containment were often seen as punitive rather than therapeutic. Sedation was most frequently used and was considered to be least distressing. Observing methods of forced/involuntary containment caused further distress.

CONCLUSIONS

There is a need to humanize service users' experiences during episodes of acute illness. Measures should include prevention of human rights abuses; minimization of isolation and distress; improvement of communication between service providers and service users; and promotion of attitudinal changes which reflect respect for other people's dignity.

Violent behavior in acute psychiatric inpatient facilities: a national survey in Italy

Violence committed by acute psychiatric inpatients represents an important and challenging problem in clinical practice. Sociodemographic, clinical, and treatment information were collected for 1324 patients (677 men and 647 women) admitted to Italian public and private acute psychiatric inpatient facilities during an index period in 2004, and the sample divided into 3 groups: nonhostile patients (no episodes of violent behavior during hospitalization), hostile patients (verbal aggression or violent acts against objects), and violent patients (authors of physical assault). Ten percent (N = 129) of patients showed hostile behavior during hospitalization and 3% (N = 37) physically assaulted other patients or staff members. Variables associated with violent behavior were: male gender, <24 years of age, unmarried status, receiving a disability pension, having a secondary school degree, compulsory admission, hostile attitude at admission, and a diagnosis of schizophrenia, bipolar disorder, personality disorder, mental retardation, organic brain disorder or substance/alcohol abuse. Violent behavior during hospitalization was a predictive factor for higher Brief Psychiatric Rating Scale scores and for lower Personal and Social Performance scale scores at discharge. Despite the low percentage of violent and hostile behavior observed in Italian acute inpatient units, this study shed light on a need for the careful assessment of clinical and treatment variables, and greater effort aimed at improving specific prevention and treatment programs of violent behavior.

Attitude of young psychiatrists toward coercive measures in psychiatry: a case vignette study in Japan

BACKGROUND

Every psychiatrist must pay careful attention to avoid violating human rights when initiating coercive treatments such as seclusion and restraint. However, these interventions are indispensable in clinical psychiatry, and they are often used as strategies to treat agitated patients. In this study, we investigated young psychiatrists' attitudes toward psychiatric coercive measures.

METHODS

A total of 183 young psychiatrists participated as subjects in our study. A questionnaire with a case vignette describing a patient with acute psychosis was sent to the study subjects via the Internet or by mail. This questionnaire included scoring the necessity for hospitalization, and the likelihood of prescribing seclusion and/or restraint, on a 9-point Likert scale (with 9 indicating strong agreement).

RESULTS

There was general agreement among the study subjects that the case should be admitted to a hospital (8.91 +/- 0.3) and secluded (8.43 +/- 1.0). The estimated length of hospitalization was 13.53 +/- 6.4 weeks. Regarding the likelihood of prescribing restraint, results showed great diversity (5.14 +/- 2.5 on 9-point scale); psychiatrists working at general hospitals scored significantly higher (6.25 +/- 2.5) than those working at university hospitals (5.02 +/- 2.3) or psychiatric hospitals (4.15 +/- 2.6). A two-group comparison of the length of inpatient care revealed a significant difference between those psychiatrists who scored 1-3 (n = 55, 14.22 +/- 7.4 wks) and those who scored 7-9 (n = 62, 12.22 +/- 4.0) regarding the need to use restraint.

CONCLUSION

Our results may reflect the current dilemma in Japanese psychiatry wherein psychiatrists must initiate coercive measures to shorten hospitalization stays. This study prompted its subject psychiatrists to consider coercive psychiatric treatments.

The distribution and frequency of seclusion and/or restraint among psychiatric inpatients

This paper reports on the frequency and distribution of seclusion or restraint (SR) episodes among 1,266 adult inpatients at a state psychiatric hospital during the 2004 calendar year. Data on the concentration of SR episodes over patients and time can assist in planning alternative, recovery-oriented treatment models. Fifteen percent (N = 194) of patients experienced seclusion or restraint. Sixty-three percent of all seclusion hours were concentrated among only ten patients. Likewise, the ten patients with the most restraint hours constituted nearly 65% of total restraint hours for the year and 48% of all restraint episodes. Variables accessible through administrative data accounted for modest seclusion and restraint variance. A comprehensive strategy to prevent SR episodes requires tailored interventions targeted to known high-risk individuals and development of general hospital-wide alternatives to SR. General alternatives require greater attention to staff education, administrative oversight, de-escalation and debriefing practices, patient involvement, and other recovery-oriented practices to reduce or eliminate use of seclusion and restraint.

A systematic review of the international published literature relating to quality of institutional care for people with longer term mental health problems

BACKGROUND

A proportion of people with mental health problems require longer term care in a psychiatric or social care institution. However, there are no internationally agreed quality standards for institutional care and no method to assess common care standards across countries. We aimed to identify the key components of institutional care for people with longer term mental health problems and the effectiveness of these components.

METHODS

We undertook a systematic review of the literature using comprehensive search terms in 11 electronic databases and identified 12,182 titles. We viewed 550 abstracts, reviewed 223 papers and included 110 of these. A "critical interpretative synthesis" of the evidence was used to identify domains of institutional care that are key to service users' recovery.

RESULTS

We identified eight domains of institutional care that were key to service users' recovery: living conditions; interventions for schizophrenia; physical health; restraint and seclusion; staff training and support; therapeutic relationship; autonomy and service user involvement; and clinical governance. Evidence was strongest for specific interventions for the treatment of schizophrenia (family psychoeducation, cognitive behavioural therapy (CBT) and vocational rehabilitation).

CONCLUSION

Institutions should, ideally, be community based, operate a flexible regime, maintain a low density of residents and maximise residents' privacy. For service users with a diagnosis of schizophrenia, specific interventions (CBT, family interventions involving psychoeducation, and supported employment) should be provided through integrated programmes. Restraint and seclusion should be avoided wherever possible and staff should have adequate training in de-escalation techniques. Regular staff supervision should be provided and this should support service user involvement in decision making and positive therapeutic relationships between staff and service users. There should be clear lines of clinical governance that ensure adherence to evidence-based guidelines and attention should be paid to service users' physical health through regular screening.

The use of seclusion in the Netherlands compared to countries in and outside Europe

The use of seclusion in psychiatric practice is a contentious issue in the Netherlands as well as other countries in and outside Europe. The aim of this study is to describe Dutch seclusion data and compare these with data on other countries, derived from the literature. An extensive search revealed only 11 articles containing seclusion rates of regions or whole countries either in Europe, Australia or the United States. Dutch seclusion rates were calculated from a governmental database and from a database covering twelve General Psychiatric Hospitals in the Netherlands. According to the hospitals database, on average one in four hospitalized patients experienced a seclusion episode. The mean duration according to the governmental database is a staggering 16 days. Both numbers seem much higher than comparable numbers in other countries. However, different definitions, inconsistent methods of registration, different methods of data collection and an inconsistent expression of the seclusion use in rates limit comparisons of the rates found in the reviewed studies with the data gathered in the current study. Suggestions are made to improve data collection, to enable better comparisons.

Successful interventions on an organisational level to reduce violence and coercive interventions in in-patients with adjustment disorders and personality disorders

Background

Self-directed and other violence as well as subsequent coercive interventions occur in a substantial proportion of patients with personality disorders during in-patient treatment. Different strategies may be required to reduce coercive interventions for patients of different diagnostic groups.

Methods

We specialised one of our acute admission wards in the treatment of personality disorders and adjustment disorders (ICD-10 F4 and F6). Patients are not transferred to other acute wards in case of suicidal or violent behaviour. Violent behaviour and coercive interventions such as seclusion or restraint were recorded in the same way as in the rest of the hospital. We recorded the percentage of subjects affected by diagnostic group and average length of an intervention in the year before and after the change in organisational structure.

Results

The total number of coercive interventions decreased by 85% both among patients with an F4 and those with an F6 primary diagnosis. Violent behaviours decreased by about 50%, the proportion of involuntary committed patients decreased by 70%.

Conclusion

The organisational change turned out to be highly effective without any additional cost of personnel or other resources.

'It's part of the job, but it spoils the job': a phenomenological study of physical restraint

This paper examines mental health nurses' experiences of physical restraint in an acute inpatient psychiatric setting using Van Manen's descriptive hermeneutic phenomenological methodology. The aim was to understand the nurses' experiences of physical restraint. One overarching theme emerged from the analysis: It's part of the job. This theme had a subtheme of Control which was constituted by the Conflicted Nurse and the Scared Nurse. The findings suggest that mental health nurses are very uncomfortable with physical restraint despite it being taken-for-granted as integral to their role. The nurses experienced conflict and fear associated with the procedure and would prefer to utilize other de-escalation skills if it was possible. The main source of conflict related to the imperative to maintain control and the professional values of the therapeutic relationship. While the nurses could see no viable alternative in some situations, the paper concludes that while environmental issues impact on the practice of physical restraint mental health nurses need to practice it with as much care and humanity as possible.

Professionals' attitudes toward reducing restraint: the case of seclusion in the Netherlands

INTRODUCTION

Despite public opinion and policy interventions, restraint remains a common practice. This is also the case in the Netherlands, where projects aimed to reduce seclusion, have not led to a decreased use of restraint. Is this lack of effectiveness related to attitudes of the professionals? The aim of this study was to explore the attitudes of professionals working in mental health care toward restraint.

METHOD

A questionnaire with eight scales was constructed for measuring attitudes of professionals. Scores of 540 professionals were studied, using analysis of variance and cluster analysis and related to several personnel and organizational characteristics.

RESULTS

The more professionals were personally involved in seclusion, the more they believed in it. Three types of professionals were identified: Transformers, Doubters and Maintainers. More than half of the psychiatrists (56%) belonged to the type of maintainers. Nurses were more divided.

CONCLUSION

Professionals working in clinical settings are not really opposed to restraint. This could explain the limited effects of innovation projects.

Factors associated with the use of physical restraints for agitated patients in psychiatric emergency rooms

OBJECTIVE

To examine factors associated with physical restraint in psychiatric emergency rooms.

METHOD

We extracted variables likely to predict use of physical restraints from a large randomised trial undertaken in three psychiatric emergency rooms in Rio de Janeiro. We fitted a Bayesian binary multivariate model using only variables clearly preceding the restraints.

RESULTS

Of 301 agitated, aggressive people admitted to emergency rooms, 73 (24%) were restrained during the first 2 h of admission. In Rio, younger people (OR=1.03 for each year younger), exhibiting intense (OR=2.53) or extreme agitation (OR=7.71), thought to result from substance misuse (OR=1.75) or diagnoses other than psychosis (OR=1.88), arriving in the morning (OR=1.64) were at greater risk of physical restraints than older, less severely aggressive or agitated people, arriving at the hospital during the afternoon or night. Hospital, gender, first admission to hospital and medication were not associated with risk of being restrained.

CONCLUSION

Restraint practices in Rio are predictable and based on a limited clinical assessment. Predictive factors for physical restraint may vary worldwide, but should be monitored and studied to assist training, and to establish programs to evaluate and refine this controversial practice.

Compulsory psychiatric care in Sweden: development 1979-2002 and area variation

As in many other countries, the Swedish legislation on compulsory psychiatric care has been revised several times during the last four decades. Great regional differences within the country in the use of compulsory psychiatric care have been reported. The aims of this study were to describe the development of compulsory psychiatric care in Sweden 1979-2002, and to analyse differences between two groups of counties, one group with high and one with low civil commitment rates, in terms of psychiatric care structure, resources and processes. Data on civil commitments and forensic psychiatric care in Sweden 1979-2002 were collected from public statistics. At least one responsible person in leading position (administrative manager or chief psychiatrist) in each of the included counties was interviewed. The total number of involuntarily hospitalised patients decreased about 80% between censuses in 1979 and 2002, but the rates of forensic patients were unchanged. No clear-cut differences were found in the analyses of structure, resources and processes of psychiatric services between counties with high and counties with low levels of compulsory care. The equality before the law may be questioned. The importance of leadership is emphasised for future analyses.

Psychiatric advance directives and reduction of coercive crisis interventions

BACKGROUND: Psychiatric advance directives are intended to enable self-determined treatment for patients who lose decisional capacity, and thus reduce the need for coercive interventions such as police transport, involuntary commitment, seclusion and restraints, and involuntary medications during mental health crises; whether PADs can help prevent the use of these interventions in practice is unknown. AIMS: This study examined whether completion of a Facilitated Psychiatric Advance Directive (F-PAD) was associated with reduced frequency of coercive crisis interventions. METHOD: The study prospectively compared a sample of PAD completers (n=147) to non-completers (n=92) on the frequency of any coercive interventions, with follow-up assessments at 6, 12, and 24 months. Repeated-measures multiple regression analysis was used to estimate the effect of PADs. Models controlled for relevant covariates including a propensity score for initial selection to PADs, baseline history of coercive interventions, concurrent global functioning and crisis episodes with decisional incapacity. RESULTS: F-PAD completion was associated with lower odds of coercive interventions (adjusted OR=0.50; 95% CI=0.26-0.96; p < 0.05). CONCLUSIONS: PADs may be an effective tool for reducing coercive interventions around incapacitating mental health crises. Less coercion should lead to greater autonomy and self-determination for people with severe mental illness.

Managing treatment resistant violent adolescents: a step forward by substituting seclusion for mechanical restraint?

Despite a growing consensus that seclusion or restraint should never be used with children or adolescents, there are a few patients who are resistant to treatment, and are persistently violent. The purpose of this study was to measure the efficacy of installing a padded seclusion room to decrease the use of mechanical restraints, a potentially more emotionally traumatic and dangerous intervention than seclusion. After padded room installation, the number of monthly mechanical restraint events per 1000 patient days decreased by 93.7%, from 21.2 to 1.3. A padded seclusion room may offer a safer, albeit a less than desirable alternative to mechanical restraint.

Interventions for reducing the use of seclusion in psychiatric facilities: review of the literature

BACKGROUND

The authors of a recent systematic review concluded that the use of non-pharmacological containment methods, excluding restraint and seclusion, was not supported by evidence. Their focus on randomised, controlled trials, however, does not reflect the research that has been, or could be, conducted.

AIMS

To find empirically supported interventions that allow reduction in the use of seclusion in psychiatric facilities.

METHOD

We reviewed English-language, peer-reviewed literature on interventions that allow reduction in the use of seclusion.

RESULTS

Staff typically used multiple interventions, including state-level support, state policy and regulation changes, leadership, examinations of the practice contexts, staff integration, treatment plan improvement, increased staff to patient ratios, monitoring seclusion episodes, psychiatric emergency response teams, staff education, monitoring of patients, pharmacological interventions, treating patients as active participants in seclusion reduction interventions, changing the therapeutic environment, changing the facility environment, adopting a facility focus, and improving staff safety and welfare.

CONCLUSIONS

Reducing seclusion rates is challenging and generally requires staff to implement several interventions.

Violence and aggression: a literature review

This paper reports the results of a literature review that was undertaken to provide background for a small pilot study that introduced violence measurement instruments that was to assist the development of nursing practice on an acute psychiatric unit. Multiple databases were searched, focusing on publications since 1994: CINAHL, Ovid Healthstar, Ovid MEDLINE (R), EMBASE, and PsycINFO. The search used the following four groups of key word alternatives (used in truncated form to allow for ending permutations) in combination with each other: violence, aggression, dangerous; prediction, assessment, factor, risk, issue, cause, reason; mental, psychiatric; inpatient, short-term, acute, admission. Searching was supplemented with footnote chasing of those papers retrieved and existing resources of the first author. Consequently, the synthesis of the results discussed cannot be considered a systematic review of the literature and is a reflection of some of the key issues found in the literature.

Decreasing the use of restraint and seclusion among psychiatric inpatients

OBJECTIVE

We describe a hospital-wide effort to decrease restraint and seclusion of psychiatric inpatients. Our hypotheses were that interventions could reduce the number of patients as well as patient hours in restraint and seclusion, without an increase in adverse outcomes (fights/assaults, staff injuries, and elopements).

METHOD

This study was performed at an urban academic psychiatric hospital (New York State Psychiatric Institute) with 3 inpatient units totaling 58 beds. Interventions included 1) decreasing initial time in restraint or seclusion from 4 to 2 hours before a new order was required; 2) education of staff concerning identification of patients at risk of restraint or seclusion and early interventions to avoid crises; and 3) use of a coping questionnaire to assess patient preferences for dealing with agitation. Data were assessed 20 months before and 67 months following the implementation of these interventions.

RESULTS

The mean number of patients restrained went from 0.35 +/- 0.6 to 0.32 +/- 0.5 patients/month; mean hours of restraint decreased from 1.7 +/- 5.2 to 1.0 +/- 2.4 hours/month. The mean number of patients secluded decreased significantly from 3.1 +/- 1.4 to 1.0 +/- 1.1 patients/month. The mean hours of seclusion decreased markedly, from 41.6 +/- 52 to 2.7 +/- 4.5 hours/month. Adverse outcomes (elopements and fights/assaults) also decreased significantly over the follow-up period.

CONCLUSIONS

Interventions were successful in decreasing use of restraint and seclusion on both clinical and research units over more than 5 years of follow-up. Such interventions may be adapted to other settings.

A 15-year national follow-up: legislation is not enough to reduce the use of seclusion and restraint

BACKGROUND

Seclusion and restraint are frequent but controversial coercive measures used in psychiatric treatment. Legislative efforts have started to emerge to control the use of these measures in many countries. In the present study, the nationwide trends in the use of seclusion and restraint were investigated in Finland over a 15-year span which was characterised by legislative changes aiming to clarify and restrict the use of these measures.

METHOD

The data were collected during a predetermined week in 1990, 1991, 1994, 1998 and 2004, using a structured postal survey of Finnish psychiatric hospitals. The numbers of inpatients during the study weeks were obtained from the National Hospital Discharge Register.

RESULTS

The total number of the secluded and restrained patients declined as did the number of all inpatients during the study weeks, but the risk of being secluded or restrained remained the same over time when compared to the first study year. The duration of the restraint incidents did not change, but the duration of seclusion increased. A regional variation was found in the use of coercive measures.

CONCLUSION

Legislative changes solely cannot reduce the use of seclusion and restraint or change the prevailing treatment cultures connected with these measures. The use of seclusion and restraint should be vigilantly monitored and ethical questions should be under continuous scrutiny.

Seclusion and restraint in patients with schizophrenia: clinical and biographical correlates

Seclusion and restraint represent adverse experiences that cause negative attitudes against psychiatric treatment and psychopathologic sequels such as posttraumatic stress disorder. We examined 117 consecutive admissions with schizophrenia, with an average of 8.7 previous admissions. Positive and Negative Syndrome Scale and Global Assessment of Functioning were obtained at admission and discharge, and traumatic events in the biography were recorded using the Posttraumatic Diagnostic Scale. Twenty-four men (42.9%) and 18 women (29.0%) had experienced seclusion or restraint in their psychiatric history. Seclusion or restraint during the present admission was best predicted in a logistic regression model by physical aggressive behavior [odds ratio (OR), 11.5] and the Positive and Negative Syndrome Scale hostility item at admission (OR, 23.6). Seclusion or restraint ever in the psychiatric history, however, was mostly associated with lifetime exposure to life-threatening traumatic events (OR, 7.2). We conclude that exposure to traumatic events in the biography severely enhances the risk of revictimization and retraumatization during inpatient treatment.

Organizational and unit factors contributing to reduction in the use of seclusion and restraint procedures on an acute psychiatric inpatient unit

OBJECTIVE

The use of seclusion or restraint (S/R) as an emergency medical intervention to assist patients in regaining behavioral control continues to be an area of interest and concern for the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), consistent with the ongoing concerns in the medical, patient advocate, legislative and legal communities. This study examined unit characteristics and the use of S/R in a VA facility with a secured, acute mental health unit before and after the promulgation of the JCAHO 2000 standards for utilization of S/R for behavioral health reasons.

METHODS

Variables examined include patient acuity, patient census, number of admits, number of discharges, length of stay, number of nursing staff on duty, critical incidents and S/R hours per month.

RESULTS

Results indicated S/R use began showing a notable decrease corresponding to the time that senior unit management began discussions of the new JCAHO standards. These reductions maintained statistical significance even after controlling for changes in unit environmental variables.

The influence of staffing levels on the use of seclusion

This study focussed on the relationship between the use of seclusion and staff characteristics, such as number of nurses on shift, male-female staff ratio, level of education and level of work experience. A retrospective analysis of staff characteristics was applied to administrative data from ten wards in four mid-sized general psychiatric hospitals in the Netherlands. The data show that two variables were associated with seclusion rates: the male-female staff ratio and the variability in team's work experience. More female and less male nurses in a shift and less variability in team's work experience predicted an increase in seclusion rates.

Are patients' views on seclusion associated with lack of privacy in the ward?

The lack of single-bed rooms in psychiatric wards may reduce the possibility of patients getting sufficient rest and privacy and may increase their risk of being overstimulated. This study explored whether residing in single- versus multiple-bed rooms in a psychiatric ward was associated with psychiatric patients' opinions about seclusion. More specifically, it was studied whether patients who had shared a room with other patients prior to seclusion rated seclusion more favorably. It was thought that they would rate seclusion more favorably due to the lack of rest they previously experienced in their regular room. For this, the Patient View-of-Seclusion Questionnaire of Hammill, McEvoy, Koral, and Schneider [Hammill, K., McEvoy, J., Koral, H., & Schneider, N. (1989). Hospitalized schizophrenic patient views about seclusion. Journal of Clinical Psychiatry, 50, 174-177] was completed by 54 secluded adult patients hospitalized in a locked ward of a Dutch psychiatric hospital. A significant association was found between residing in multiple-bed rooms prior to seclusion and a less negative view on seclusion. This finding suggests that the ward environment may have a rather large impact on how seclusion is perceived. The results underline the need for single-bed rooms in the treatment of psychiatric inpatients.

On conflict, containment and the relationship between them

A programme of research into conflict (e.g. violence, absconding, medication refusal) and containment (e.g. seclusion, special observation, physical restraint) in inpatient psychiatry has been under way at City University, London, UK, for the past 10 years. Recent research findings, plus the challenges posed by ongoing projects, have made apparent the need for greater clarity about the overarching concepts of 'conflict' and 'containment'. This paper pulls together research findings pertaining to this issue, and conducts a reasoned analysis of what common characteristics might underlie 'conflict' and 'containment'. It is concluded that these are patient threats to safety, and the staff maintenance of safety. Details are presented on the inclusions and exclusions that follow from taking such a position, and potential definitions offered. On the grounds of this conceptual analysis, plus evidence for moderate degrees of statistical association between behaviours and events in each domain, it is concluded that it is legitimate to conduct analyses at the level of total conflict and containment rates, as well as at the level of individual types of behaviours and events (e.g. verbal abuse, sedation). Some of the mathematical difficulties in the analysis of total conflict and containment are addressed, and results of a weighting exercise presented. This exercise challenges our perception of the severity of some containment measures that are becoming more commonly used in acute psychiatry.

Forensic psychiatric aspects of inpatient violence

Inpatient aggression jeopardizes the safety of psychiatric clinicians and patients. A minority of psychiatric inpatients is responsible for most of inpatient assaults; this subset of repetitively assaultive patients warrants greater attention in the form of systematic study. In developing treatment approaches for assaultive inpatients, it is important to characterize the primary motivation driving aggressive behavior. There are many pharmacologic agents and psychotherapeutic approaches available to address inpatients who engage in impulsive and psychotic violence, but the treatment of inpatients with antisocial or psychopathy personality remain limited, and further study is needed. To protect the safety of patients and staff, criminal prosecution of inpatient assaults is clinically justified if an assailant continues to be aggressive despite appropriate clinical interventions or commits an act of planned aggression so egregious that prosecution is the only reasonable alternative.

Managing the aggressive and violent patient in the psychiatric emergency

Throughout history most societies have assumed a link between mental disorders and violence. Although the majority of users of mental health services are not violent, it is clear that a small yet significant minority are violent in inpatient settings and in the community. The assessment of a violent patient may be very difficult due to the lack of a full medical and psychiatric history and the non-cooperativeness of the patient. Thus a full assessment is important for the early decisions that the clinician has to take in a very quick and effective way. The primary task and the short term outcome in a behavioral emergency is to act as soon as possible to stop the violence from escalating and to find the quickest way to keep the patient's agitation and violence under control with the maximum of safety for everybody and using the less severe effective intervention. The pharmacological treatment of acute, persisting and repetitive aggression is a serious problem for other patients and staff members. Currently, there is no medication approved by the Food and Drug Administration (FDA) for the treatment of aggression. Based on rather limited evidence, a wide variety of medications for the pharmacological treatment of acute aggression has been recommended: typical and atypical antipsychotics and benzodiazepines.

Relating Outcomes to Excellent Nursing Practice

Healthcare professionals must find ways to accelerate the diffusion of knowledge within their organizations. Although nurses have extraordinary access to patient care data, they may underestimate their roles as data managers and innovators of change, and relinquish control of data to others. The authors discuss how nurses at an acute psychiatric hospital collect and report their own data to show the direct relationship between outcomes and excellence in nursing practice. Knowledge that is gained through practice is shared to inspire and sustain needed changes.

Restraint use for psychiatric patients in the pediatric emergency department

BACKGROUND

Restraint of children and adolescents with psychiatric problems has generated controversy. Restraint may be defined as methods used to restrict movement or normal access to one's body. Published data to guide restraint practice are limited.

OBJECTIVE

To examine frequency of restraint use and patient demographics and chief complaints associated with restraint use in our pediatric emergency department.

METHODS

We retrospectively reviewed the pediatric emergency department records of children (age <18 years) who underwent emergency psychiatric evaluation in an urban general hospital from January 2001 to December 2002. Factors associated with restraint use were determined using multivariate logistic regression.

RESULTS

Data were available for 1125 (82%) of 1371 patients who underwent emergency psychiatric evaluation; 76 (6.8%) of 1125 patients were restrained: 37 physical, 19 with medication, and 20 both. Study patients were mean age 13.1 years, 50% girls, 54% blacks, 19% Latinos, and 18% whites; 80% had public insurance. Boys were restrained more often than girls (8.7% vs. 5.2%, P = 0.02). Age, insurance, and race were not associated with restraint use. Patients admitted for inpatient psychiatric care were restrained more frequently than those discharged home (9.9% vs. 3.9%, P < 0.001). In multivariate logistic regression, sex was not associated with restraint use. Restraint use was associated with chief complaints of visual hallucinations (odds ratio, 5.29), out-of-control behavior (odds ratio, 4.65), hyperactivity (odds ratio, 2.26), and admission to a psychiatric facility (odds ratio, 2.40).

CONCLUSIONS

Approximately 1 in 15 children undergoing psychiatric evaluation were restrained. This is the first study to elucidate correlates of restraint practice in the pediatric emergency department. Further studies examining indications for restraint and comparing methods of restraint are needed.

Effects of a psychiatric intensive care unit in an acute psychiatric department

Psychiatric acute units use different levels of segregation to satisfy needs for containment and decrease in sensory input for behaviourally disturbed patients. Controlled studies evaluating the effects of the procedure are lacking. The aim of the present study was to compare effects in acutely admitted patients with the use of a psychiatric intensive care unit (PICU) and not in a psychiatric acute department. In a naturalistic study, one group of consecutively referred patients had access only to the PICU, the other group to the whole acute unit. Data were obtained for 56 and 62 patients using several scales. There were significant differences in reduction of behaviour associated with imminent, threatening incidents (Broset Violence Checklist), and actual number of such incidents (Staff Observation Aggression Scale-Revised) in favour of the group that was treated in a PICU. The principles of patient segregation in PICUs have favourable effects on behaviours associated with and the actual numbers of violent and threatening incidents.

Coercion in psychiatric care: clinical, legal, and ethical controversies

Despite a long-standing tradition of the use of coercion in psychiatric care, such as involuntary admission and treatment, few have systematically addressed this issue. In recent years, more research has been carried out, suggesting that the use of coercion has important and complex legal, ethical, and clinical implications. In the present article, types and rates of coercion are presented and central topics including competency, ethics, and the reasons given for the use of coercion, are critically discussed.

Transforming systems of care: the American Association of Community Psychiatrists Guidelines for Recovery Oriented Services

Thinking about recovery has grown significantly over the last 70 years, and particularly in the past fifteen. Promotion of recovery has recently been recognized as an organizing principle for the transformation of behavioral health services. Recovery is a personal process of growth and change which typically embraces hope, autonomy and affiliation as elements of establishing satisfying and productive lives in spite of disabling conditions or experiences. Recovery oriented services replace paternalistic, illness oriented perspectives with collaborative, autonomy enhancing approaches and represent a major cultural shift in service delivery. Recovery oriented services replace the myth of chronicity and dependence with a message of individualism, empowerment and choice in the context of collaborative relationships with service providers. The American Association of Community Psychiatrists has developed Guidelines for Recovery Oriented Services to facilitate the transformation of services to this new paradigm. The guidelines are divided into three domains: administration, treatment, and supports, each consisting of several elements for which recovery enhancing characteristics are defined. Several example indicators are also provided for each element. This paper presents these guidelines and discusses their application.