Implementing a Psychiatric Behaviours of Concern emergency team in an acute inpatient psychiatry unit: Staff perspectives

Behaviours of concern including aggression are widespread in mental health inpatient settings. Restrictive interventions such as restraint and seclusion can cause additional trauma to already traumatized patients. To decrease use of these interventions in an acute psychiatric unit in Melbourne, Australia, a Psychiatric Behaviours of Concern (Psy-BOC) response team was introduced. In a Psy-BOC call, senior medical, nursing, and allied health staff respond to escalating behavioural situations to work with the primary treating team to implement clinical interventions of least restrictive practice. Here, we present qualitative findings reporting staff response to Psy-BOC. The study complied with the Consolidated Criteria for Reporting Qualitative Research (COREQ). Twenty-four staff participated in five focus groups. Four themes were identified: Identifying behavioural deterioration, responding to behaviours of concern, staff reactions, and barriers. Although staff were skilled in recognizing and de-escalating behaviours of concern, patients were secluded when heightened risk was perceived. The adoption of Psy-BOC was met with some resistance to the cultural change required to adopt this new model. Increased awareness, early identification of behaviours of concern, and pressure from management resulted in reductions in restrictive interventions. Management of patients with drug-induced psychosis without restraint presented specific difficulties. The ward setting was challenging, offering no break-out spaces for patients, and few comfortable areas. Some staff appreciated the advice and expertise of the Psy-Boc team, others felt disempowered and undermined. Improving leadership, staff education, support and collaboration, and including frontline staff in refining the process could enhance the Psy-BOC response and increase safety for all.

Reducing seclusion and restraint in a child and adolescent inpatient area: implementation of a collaborative problem-solving approach

OBJECTIVE

The aim of this study was to determine whether implementation of a collaborative problem-solving approach would be associated with a decrease in seclusion and restraint in a child and adolescent inpatient unit.

METHOD

A collaborative problem-solving (CPS) approach was implemented. Seclusion and restraint, length of treatment, clinician- and patient/parent-rated outcomes and staff utility and acceptability were surveyed pre and post implementation.

RESULTS

The number of restrictive events significantly decreased, including full restraint, partial restraint and seclusion. Length of treatment and routine clinician-rated outcome measures remained consistent. Patient or parent-rated outcomes showed greater reduction post implementation. Despite some initial scepticism, the staff found this approach useful.

CONCLUSIONS

A CPS approach was successfully implemented, and in this naturalistic study was associated with a significant decrease in seclusions and restraints.

Seclusion, restraint, and involuntary medication in Finnish psychiatric care: a register study with root-level data

Purpose: Despite potentially harmful effects, seclusion, restraint, and involuntary medication continue to be frequently applied in psychiatric care. These restrictive measures are often examined by means of registers, but homogeneous practices in the measurement and description seem to be missing. This nationwide register study aimed to examine the use of seclusion, mechanical and physical restraint, and involuntary medication in Finland.Material and methods: Root-level register data concerning the year 2017 were collected directly from 140 inpatient psychiatric wards within 21 organizations. The data were analyzed statistically.Results: In 2017, the most used restrictive measure in Finnish psychiatric wards was seclusion (4006 episodes), followed by involuntary medication (2187 episodes), mechanical restraint (2113 episodes) and physical restraint (1064 events). Similarly, the duration of seclusion episodes was longer than the duration of restraint episodes. Remarkable variation between wards in the use of seclusion, restraint and involuntary medication was observable. A negative binomial regression model (NB2) was used to analyze the associations between the use of restrictive measures and regional variables concerning demography, health, substance abuse, and socio-economic status, but reliable interpretations were impossible to generate.Conclusion: This study provides detailed and unique data on the use of seclusion, restraint and involuntary medication in Finland. Compared to previous national-level data, this study highlights the importance of collecting root-level data. Future research should use registries and describe the associations between the use of restrictive measures and ward-level factors, patient-level characteristics, and societal factors.

Nurses' perceptions of risks for occupational hazards in patient seclusion and restraint practices in psychiatric inpatient care: A focus group study

Seclusion and restraint are regularly used to manage patient aggression events in psychiatric inpatient care, despite occupational safety concerns. There is currently a lack of information on how nurses perceive the use of patient seclusion and restraint as a risk for occupational safety. The aim of this study is to describe the risks for occupational hazards in patient seclusion and mechanical restraint practices as well as ideas for improvement identified by nurses. A qualitative descriptive design was adopted, using focus groups comprising nurses (N = 32) working in psychiatric inpatient care. The data were analysed using inductive content analysis, and the results were reported using the consolidated criteria for reporting qualitative studies (COREQ). Four themes of risk for occupational hazards were identified: patient-induced, staff-induced, organization-induced, and environment-induced risks. One significant finding was that nurses described that their actions can strongly contribute to occupational hazards during seclusion and mechanical restraint practices. The nurses gave various ideas for how occupational safety could be improved during seclusion and mechanical restraint events, ideas involving staff, the organization, and environmental enhancements.

The role of interpersonal style in aggression and its containment in a forensic mental health setting: A correlational and pseudoprospective study of patients and nursing staff

Inpatient aggression on mental health wards is common and staff-patient interactions are frequently reported antecedents to aggression. However, relatively little is known about the precise relationship between aggression and these interactions, or their relationships with aggression and staff containment responses such as restraint and seclusion. This study aimed to determine the roles of anger and interpersonal style among mental health nurses and between nurses and patients in the occurrence of aggression and its containment. A correlational, pseudoprospective study design was employed. n = 85 inpatients and n = 65 nurses were recruited from adult, low- and medium-secure wards of a secure forensic mental health service. Participants completed validated self-report anger and transactional interpersonal style measures. Inpatient aggression and containment incident data for a 3-month follow-up period were extracted from clinical records. Dyadic nurse-patient relationships were anticomplementary. Patients' self-reported anger and staff-rated hostile interpersonal style were significantly positively correlated; staff self-reported anger and patient-rated dominant interpersonal style were also positively correlated. Patient anger predicted aggression and their interpersonal style predicted being subject to containment in the form of restraint and seclusion. There were no statistically significant differences identified on measures between staff who were and were not involved in containment. More targeted intervention for patients' anger may have a positive impact on interpersonal style and lead to the reduction of incidents. Staff education and skills training programmes should emphasize the importance of interpersonal styles which could help to promote and enhance positive interactions.

Behavior Modification Is Associated With Reduced Psychotropic Medication Use in Children With Aggression in Inpatient Treatment: A Retrospective Cohort Study

OBJECTIVE

There are few data to guide management of agitated and aggressive psychiatrically hospitalized children. Available studies do not account for setting, age, sex, diagnosis, admission reason, or clinical intervention. Seclusion, restraint, and physical holds (S/R/H) are usually the only outcome measure. In this study, we examine changes in PRN (pro re nata, or "as needed") psychotropic medication use to manage severe aggression on a children's psychiatric inpatient unit, comparing rates before and after a behavior modification program (BMP) was discontinued.

METHOD

We compare 661 children (aged 5-12 years) in 5 cohorts over 10 years, 510 (77%) of whom were admitted for aggressive behavior. PRN use per 1,000 patient-days was the primary outcome measure, but S/R/H was also examined. We use the following as predictors: BMP status, full- or half-time child and adolescent psychiatrist (CAP) oversight, diagnosis, age, length of stay, and neuroleptic use.

RESULTS

Children admitted for aggression had high rates of externalizing disorders (79%), low rates of mood (27%) and anxiety (21%) disorders, and significantly higher rates of PRN and S/R/H (p < .001) use. Rate of PRN use was significantly lower (p < .001) when the BMP was present (mean [SD], 163 [319] per 1,000 patient-days) than when it was absent (483 [569]; p < .001). Higher PRN use was predicted by BMP absence, neuroleptic treatment, and young patient age (p < .001), and by half-time CAP oversight (p = .002).

CONCLUSION

In this sample of young children with primarily externalizing disorders, data support the effectiveness of a BMP in lowering rates of PRN and S/R/H use.

Identifying Direct Coercion in a High Risk Subgroup of Offender Patients With Schizophrenia via Machine Learning Algorithms

PURPOSE

This study aims to explore risk factors for direct coercive measures (seclusion, restraint, involuntary medication) in a high risk subpopulation of offender patients with schizophrenia spectrum disorders.

METHODS

Five hundred sixty nine potential predictor variables were explored in terms of their predictive power for coercion/no coercion in a set of 131 (36.6%) offender patients who experienced coercion and 227 who did not, using machine learning analysis. The dataset was split (70/30%) applying variable filtering, machine learning model building, and selection embedded in nested resampling approach in one subset. The best model was then selected, and the most important variables extracted on the second data subset.

RESULTS

In the final model the following variables identified coercion with a balanced accuracy of 73.28% and a predictive power (area under the curve, AUC) of 0.8468: threat of violence, (actual) violence toward others, the application of direct coercive measures during past psychiatric inpatient treatments, the positive and negative syndrome scales (PANSS) poor impulse control, uncooperativeness, and hostility and the total PANSS-score at admission, prescription of haloperidol during inpatient treatment, the daily cumulative olanzapine equivalent antipsychotic dosage at discharge, and the legal prognosis estimated by a team of licensed forensic psychiatrists.

CONCLUSIONS

Results confirm prior findings, add detail on factors indicative for the use of direct coercion, and provide clarification on inconsistencies. Limitations, clinical relevance, and avenues for future research are discussed.

Implementation of Guidelines on Prevention of Coercion and Violence (PreVCo) in Psychiatry: Study Protocol of a Randomized Controlled Trial (RCT)

BACKGROUND

Coercive measures are among the most controversial interventions in psychiatry. There is a large discrepancy between the sheer number of high-quality guidelines and the small number of scientifically accompanied initiatives to promote and evaluate their implementation into clinical routine. In Germany, an expert group developed guidelines to provide evidence- and consensus-based recommendations on how to deal with violence and coercion in psychiatry.

METHODS

The study presented examines whether coercive measures on psychiatric wards can be reduced by means of an operationalized implementation of the guidelines "Prevention of coercion: prevention and therapy of aggressive behavior in adults". Out of a set of 12 interventions offered, wards are free to choose three interventions they want to implement. The primary outcome is the number of coercive measures per bed and month/year. Secondary outcomes are cumulative duration of coercive measures per bed and month/year. The most important control variable is the number of aggressive incidents. We plan to recruit 52 wards in Germany. Wards treating both voluntary and compulsorily admitted patients will be included. A 1:1 stratified randomized controlled trial will be conducted stratified by the amount of coercive measures and implemented aspects of the guidelines. In addition to the control group analysis, a waiting list design allows a pre-post analysis for all participating wards of the waiting list group. A parallel qualitative study will examine factors related to successful implementation and to successful reduction of coercion as well as relevant barriers.

DISCUSSION

We are planning a nationwide study on the implementation of evidence- and consensus-based guidelines in psychiatric hospitals. This study intends to promote the transfer of expert knowledge as well as results from clinical trials into clinical routine with the potential to change supply structures in mental health sector.

CLINICAL TRIAL REGISTRATION

www.isrctn.com, identifier ISRCTN71467851.

Freedom Restrictive Coercive Measures in Forensic Psychiatry

Background: In Germany, people suffering from severe mental illness who have committed serious offenses and have considerably reduced or suspended criminal responsibility can be detained and treated in forensic psychiatric hospitals. In the German federal state of Baden-Wuerttemberg, all psychiatric hospitals including forensic psychiatric hospitals are obliged to record data on every coercive intervention and to submit them to a central registry. The objective of this study was to determine key measures for the use of seclusion and restraint and to compare them with data from the same registry on the use of coercion in general inpatient mental health care. Methods: Data on the main psychiatric diagnosis according to ICD-10, type and duration of each coercive measure and number of treated cases according to diagnoses, and cumulated number of days of treatment from all 8 forensic facilities in the state of Baden-Wuerttemberg covering a catchment area with about 11 million inhabitants were collected at the treated-case-level for 3 years. Results: 22.6% of the cases treated in 2017 in forensic psychiatric hospitals were subjected to seclusion, and 3.8% were subjected to mechanical restraint. The mean cumulated duration of seclusion episodes per affected case was 343.9 h and the mean cumulated duration of restraint episodes was 261.7 h. 13.2% of the treated cases were subjected to room confinement with a mean cumulated duration of 539.1 h per affected case. Involuntary medication was applied in 1.9% of the cases. In general psychiatry, 2.9% of the treated cases were subjected to seclusion, and 4.7% were subjected to mechanical restraint. The mean cumulated duration per affected case amounted to 32.2 h for seclusion episodes and to 37.6 h for restraint episodes. Involuntary medication was applied in 0.6% of cases. Conclusion: Compared to general psychiatry, mechanical restraint is used in forensic psychiatry substantially less frequently and seclusion substantially more frequently. Room confinement is used only in forensic psychiatric hospitals. Use of involuntary medication is rare. On the one hand, recorded involuntary medication comprises only clear actions against the patient's expressed will as defined by law. Psychological pressure to take medication to avoid other forms of coercion and to achieve higher levels of freedom within the facility is not recorded. On the other hand, the low numbers of clear involuntary medication probably reflect the high legal threshold for such interventions, and, consequently, efforts by staff to motivate voluntary acceptance. The long duration of freedom-restricting coercive measures in forensic psychiatry probably reflects the selection of patients at high risk of violence.

Aims to Reduce Coercive Measures in Forensic Inpatient Treatment: A 9-Year Observational Study

Protecting the human rights is particularly important within the forensic context because patients in forensic psychiatry are not admitted voluntarily and so the treatment itself is of a coercive nature. Coercive measures (i.e., actions against the will of the patient such as forced medication, seclusion or restraint) form an additional incision of personal rights. Although the use of coercion within forensic psychiatric institutions remains controversial, little empirical research has been conducted on the use of coercive measures within forensic settings. The study presented here can contribute to close this research gap by informing about rates of coercive measures within the present institution. National and international organizations on the prevention of torture or inhuman or degrading treatment have emphasized the need to keep the incidents of coercive measures to a minimum. Criticisms by such organizations on high rates of seclusion, restraint, and compulsory medication have led to organizational changes within the present institution which is Switzerland's largest forensic clinic with an average of 124 patients per year. After a first visit of such a committee, e.g., the detailed documentation of coercive measures became obligatory and part of special reports. Changes in the use of coercive measures are presented here. Data on coercive measures was analyzed for years 2010 to 2018. With respect to the most invasive coercive measurement, restraint, a minimum of four patients in 2017 and a maximum of 14 patients in 2010 have been subject to this form of coercive measurement. A minimum of sixteen patients in 2012 and a maximum of 40 patients in 2010 were secluded. Though total number and duration show a trend towards a reduction in severity of coercive measures on average, a few patients are not responsive to deescalating interventions. Preventive mechanisms, documentation standards, and efforts to ensure humane and adequate treatment are discussed under ethical considerations of coercive measures within court mandated treatment.

Humane treatment versus means of control: coercive measures in Norwegian high-security psychiatry, 1895-1978

This article analyses the use of coercive measures in two national institutions for high-security psychiatry in Norway - Kriminalasylet (Criminal Asylum) and Reitgjerdet - during the period 1895-1978. Historical study of coercion in psychiatry is a fruitful approach to new insight into the moral and ethical considerations within the institutions. We approach the topic through a qualitative study of patient case files and ward reports from the institutions' archives, as well as a comprehensive quantification of the coercive measures used. The data show shifting considerations of humane treatment and changes in the respect for human dignity in the institutions' practices. They also show that technological developments, such as the introduction of new psychopharmaceuticals, did not necessarily lead to higher standards of treatment.

Prevalence and predictors of restrictive interventions in a youth-specific mental health inpatient unit

INTRODUCTION

The use of restrictive interventions is one of the most controversial practices in medicine. They are utilized in an inpatient setting to manage agitated or aggressive behaviour or to ensure that an individual receives the necessary treatments. However, restrictive interventions remove autonomy and adverse events can be associated with their practice. Youth-specific inpatient units (IPUs) are now being established and it is imperative that the use of restrictive interventions is reduced. In order to inform and facilitate prevention and reduction strategies, this study aimed to determine the prevalence and determinants of restrictive interventions (restraint, seclusion and medication without consent) in a youth specialist mental health IPU.

METHODS

This study was set at a 16-bed youth specialist acute IPU of Orygen Youth Health, a specialist youth mental health service that provides inpatient care for those aged 18 to 25 years within a catchment area of west and north-western regions of Melbourne, Australia. A retrospective file audit was conducted of all the admissions to the unit from 01 January 2015 to 30 June 2015.

RESULTS

Over the 6-month study period, 159 young people were admitted and this accounted for 188 admissions. Over half (54.3%) of admissions were involuntary and restrictive intervention were used in 17.6% of admissions. Specifically, 15.7% (N = 25) of young people experienced restraint, 10.1% (N = 16) were secluded, and 8.1% (N = 12) experienced medication without consent. Absent insight and involuntary status on admission were associated with restrictive interventions.

CONCLUSION

As youth mental health services develop, interventions aimed at reducing restrictive interventions are needed.

Consumer Perspectives of Safewards Impact in Acute Inpatient Mental Health Wards in Victoria, Australia

Background: Inpatient mental health wards are reported by many consumers to be custodial, unsafe, and lacking in therapeutic relationships. These consumer experiences are concerning, given international policy directives requiring recovery-oriented practice. Safewards is both a model and a suite of interventions designed to improve safety for consumers and staff. Positive results in reducing seclusion have been reported. However, the voice of consumers has been absent from the literature regarding Safewards in practice. Aim: To describe the impact of Safewards on consumer experiences of inpatient mental health services. Method: A postintervention survey was conducted with 72 consumers in 10 inpatient mental health wards 9-12 months after Safewards was implemented. Results: Quantitative data showed that participants felt more positive about their experience of an inpatient unit, safer, and more connected with nursing staff. Participants reported that the impact of verbal and physical aggression had reduced because of Safewards. Qualitatively, participants reported increased respect, hope, sense of community, and safety and reduced feelings of isolation. Some participants raised concerns about the language and intention of some interventions being condescending. Discussion: Consumers' responses to Safewards were positive, highlighting numerous improvements of importance to consumers since its implementation across a range of ward types. The findings suggest that Safewards offers a pathway to reducing restrictive interventions and enables a move toward recovery-oriented practice.

Effectiveness of six core strategies based on trauma informed care in reducing seclusions and restraints at a child and adolescent psychiatric hospital

OBJECTIVE

The purpose of the study was to determine the effectiveness of six core strategies based on trauma informed care in reducing the use of seclusion and restraints with hospitalized youth.

METHODS

The hospital staff received training inMarch 2005 in six core strategies that are based on trauma informed care. Medical records were reviewed for youth admitted between July 2004 andMarch 2007. Data were collected on demographics, including age, gender, ethnicity,number of admissions, type of admissions, length of stay, psychiatric diagnosis, number of seclusions, and restraints.

RESULTS

Four hundred fifty-eight youth (females 276/males 182) were admitted between July 2004 and March 2007. Seventy-nine patients or 17.2% (females 44/males 35) required 278 seclusions/restraints (159 seclusions/119 restraints),with average number of episodes 3.5/patient (range 1-28). Thirty-seven children and adolescents placed in seclusion and/or restraints had three or more episodes. In the first six months of study, the number of seclusions/restraints episodes were 93 (73 seclusions/20 restraints), involving 22 children and adolescents (females 11/males 11). Comparatively, in final six months of study following the training program, there were 31 episodes (6 seclusions/25 restraints) involving 11 children and adolescents (females 7/males 4). The major diagnoses of the youth placed in seclusion and/or restraints were disruptive behavior disorders (61%) and mood disorders (52%).

CONCLUSIONS

This study shows downward trend in seclusions/restraints among hospitalized youth after implementation of National Association of State Mental Health ProgramDirectors six core strategies based on trauma informed care.

Factors influencing decisions of mental health professionals to release service users from seclusion: A qualitative study

AIM

This study aims to explore and understand factors influencing the decisions of mental health professionals releasing service users from seclusion.

BACKGROUND

Seclusion should only be used as a last resort and for the minimum possible duration. Current evidence outlines which service users are more likely to be secluded, why and what influences professionals' decision to seclude. Little is known about factors professionals consider when releasing service users.

DESIGN

A qualitative study was undertaken to explore factors which influence decision-making of mental health professionals when terminating episodes of seclusion.

METHODS

Semi-structured face-to-face interviews with 21 professionals were undertaken between May 2017-January 2018. Framework analysis was used to systematically manage, analyse, and identify themes, while maintaining links to primary data and providing a transparent audit trail.

RESULTS

Six themes were identified where professionals looked for service users to demonstrate cooperation and compliance before they would be released. Decisions were subjective, being influenced by the experience and composition of the review team, the availability of resources plus the emotional tone and physical environment of the ward. Release could be delayed by policy and protocol.

CONCLUSION

Professionals should have greater awareness of factors that hinder or facilitate decisions to release service from seclusion and an understanding of how service user views and involves in decisions regarding seclusion should be explored.

IMPACT

Senior staff should be available to facilitate release at the earliest opportunity. Staff should ensure that policy and procedures do not prolong the time service users remain secluded.

Assessment of Risk for Seclusion Among Forensic Inpatients: Validation and Modification of the Risk of Administrative Segregation Tool (RAST)

Seclusion is used in psychiatric care to protect patients and staff or to manage aggression but may have adverse effects. The ability to identify at-risk patients could help reduce seclusion. This study tested the Risk of Administrative Segregation Tool's (RAST) ability to predict any seclusions among 229 male forensic inpatients followed for up to 1 year of hospitalization, and days spent secluded, controlling for length of stay. RAST scores were lower than in correctional samples. The RAST did not predict seclusions in Year 1, but modification of three items to fit the forensic population (RAST-F) offered a small improvement. Among 62 patients hospitalized for more than 1 year, the RAST significantly predicted seclusions in Year 2, and the modifications improved prediction. The present modest findings support the RAST's potential to help identify patients most in need of clinical efforts to avert seclusion. Replication in larger samples, including female patients, is needed.

Using interventions to reduce seclusion and mechanical restraint use in adult psychiatric units: an integrative review

The aim of this integrative review was to describe interventions aimed at reducing seclusion and mechanical restraint use in adult psychiatric inpatient units and their possible outcomes. CINAHL, MEDLINE, PsycINFO and Medic databases were searched for studies published between 2008 and 2017. Based on electronic and manual searches, 28 studies were included, and quality appraisal was carried out. Data were analysed using inductive content analysis. Interventions to proactively address seclusion were environmental interventions, staff training, treatment planning, use of information and risk assessment. Interventions to respond to seclusion risk were patient involvement, family involvement, meaningful activities, sensory modulation and interventions to manage patient agitation. Interventions to proactively address mechanical restraint were mechanical restraint regulations, a therapeutic atmosphere, staff training, treatment planning and review of mechanical restraint risks. Interventions to respond to mechanical restraint risks included patient involvement, therapeutic activities, sensory modulation and interventions to manage agitation. Outcomes related to both seclusion and mechanical restraint reduction interventions were varied, with several interventions resulting in both reduced and unchanged or increased use. Outcomes were also reported for combinations of several interventions in the form of reduction programmes for both seclusion and mechanical restraint. Much of the research focused on implementing several interventions simultaneously, making it difficult to distinguish outcomes. Further research is suggested on the effectiveness of interventions and the contexts they are implemented in.

Consumer recommendations for enhancing the Safewards model and interventions

This paper critiques the Safewards model through the lens of lived experiences of psychiatric hospitalization, diagnosis of mental illness, and distress. Special focus is given to the model's tested 10 interventions and to five lesser known interventions, identifying the impact they can have on hospitalized consumers. We highlight the role and prevalence of trauma, as well as the need to prevent harm in hospital settings. We draw upon notions of hospital as a sanctuary for people and the importance of providing a safe ward. 'Sanctuary harm' and 'Sanctuary trauma' are thus defined, with emphasis placed on the Safewards interventions as means by which sanctuary can be achieved. Finally, the consumer-perspective authors propose expansions to the model, critiquing the defining literature and moving towards a consumer experience of safety that is beyond the model's original intention: to reduce seclusion and restraint practices. Throughout the paper, the term 'consumer' is used in this context to mean people who have experienced or are experiencing psychiatric inpatient care.

Variation in seclusion rates across New Zealand's specialist mental health services: Are sociodemographic and clinical factors influencing this?

Rates of seclusion vary across New Zealand's publicly funded district health board (DHB) adult mental health inpatient services as indicated by national data. Anecdotally, this variation has been attributed to a range of factors directly relating to the people admitted to acute inpatient services. This study examined the extent to which variation in seclusion rates could be explained by the sociodemographic and clinical differences between populations admitted into adult mental health inpatient services. Retrospective data were obtained from the Programme for the Integration of Mental Health Data (PRIMHD). A logistic regression model was fitted to these data, with seclusion (yes/no) as the dependent variable and DHB groups as the independent variable. The DHBs were classified into four groups based on their seclusion rates. The model adjusted for ethnicity, age, number of bed nights, total Health of the Nation Outcome Scales (HoNOS) scores, and compulsory treatment status. Odds ratios remained virtually unchanged after adjustment for sociodemographic and clinical factors. People admitted to DHB Group 4 (highest secluding DHBs) were 11 times more likely to be secluded than people in Group 1 (lowest secluding DHBs), adjusted OR = 11.1, 95% CI [7.5,16.4], P < 0.001. Results indicate DHB variation in seclusion rates cannot be attributed to the sociodemographic and clinical factors of people admitted into DHB adult mental health inpatient services. Instead, this variation may be explained by differences in service delivery models and practice approaches. A model of system improvements aimed at reducing seclusion is discussed.

People who experience seclusion in adult mental health inpatient services: An examination of health of the nation outcome scales scores

The Health of the Nation Outcomes Scales (HoNOS) provides an overview of a person's behaviour, impairment, clinical symptoms, and social functioning. This study investigated the profile of people who had been secluded in New Zealand's adult mental health inpatient services using 12 individual HoNOS ratings. Routinely collected clinical data were extracted from the Programme for the Integration of Mental Health Data (PRIMHD). This is the national data set for mental health and addiction services. A logistic regression model was fitted to the data which adjusted for age, sex, ethnicity, bed nights, compulsory treatment, and district health board. After adjustment, three HoNOS items significantly predicted the risk of seclusion: overactive, aggressive, disruptive, or agitated behaviour (adjusted OR = 4.82, 95% CI [3.88, 5.97], P < 0.001); problem drinking or drug-taking (adjusted OR = 1.51, 95% CI [1.25, 1.82], P < 0.001); and problems with hallucinations and delusions (adjusted OR = 1.33, 95% CI [1.09, 1.63], P = 0.006). In addition, two HoNOS items were protective for seclusion: nonaccidental self-injury (adjusted OR = 0.65, 95% CI [0.51, 0.83], P < 0.001) and depressed mood (adjusted OR = 0.58, 95% CI [0.47, 0.72], P < 0.001). Thus, responding effectively to agitation and/or aggression, substance use, and psychosis plays an important role in reducing the use of seclusion. Mental health nurses and other workers can reduce seclusion through early assessment, effective communication, de-escalation techniques, reduction tools, trauma-informed care, and consulting with consumers and whānau.

Perceptions of nurses working with psychiatric consumers regarding the elimination of seclusion and restraint in psychiatric inpatient settings and emergency departments: An Australian survey

Seclusion and restraint continue to be used across psychiatric inpatient and emergency settings, despite calls for elimination and demonstrated efficacy of reduction initiatives. This study investigated nurses' perceptions regarding reducing and eliminating the use of these containment methods with psychiatric consumers. Nurses (n = 512) across Australia completed an online survey examining their views on the possibility of elimination of seclusion, physical restraint, and mechanical restraint as well as perceptions of these practices and factors influencing their use. Nurses reported working in units where physical restraint, seclusion, and, to a lesser extent, mechanical restraint were used. These were viewed as necessary last resort methods to maintain staff and consumer safety, and nurses tended to disagree that containment methods could be eliminated from practice. Seclusion was considered significantly more favourably than mechanical restraint with the elimination of mechanical restraint seen as more of a possibility than seclusion or physical restraint. Respondents accepted that use of these methods was deleterious to relationships with consumers. They also felt that containment use was a function of a lack of resources. Factors perceived to reduce the likelihood of seclusion/restraint included empathy and rapport between staff and consumers and utilizing trauma-informed care principles. Nurses were faced with threatening situations and felt only moderately safe at work, but believed they were able to use their clinical skills to maintain safety. The study suggests that initiatives at multiple levels are needed to help nurses to maintain safety and move towards realizing directives to reduce and, where possible, eliminate restraint use.

Patients' experiences of isolation in psychiatric inpatient care: Insights from a meta-ethnographic study

Historically, people with mental ill-health have been isolated from society. Although mental health care has moved from closed to more open forms of care, in many societies care is still provided in locked wards, and people with mental ill-health are sometimes secluded from their fellow patients, families, friends, and visitors. The aim of this study was to illuminate patients' experiences of isolation in psychiatric inpatient care. A systematic review of qualitative research was conducted, and the key findings were subjected to meta-ethnographic synthesis. The findings were twofold: 'being admitted to prison' and 'having access to shelter'. The experience of isolated care as prison-like symbolizes patients' longing for freedom and feeling restricted and limited by rules, stripped of rights, abandoned, controlled, powerless, and unsupported. In contrast, the experience of isolation as shelter symbolizes safety and the opportunity to regain control over one's own situation. A stigmatizing public view holds that people with mental ill-health are dangerous and unpredictable and, therefore, unsafe to themselves and others. Being placed in isolation because these fears contribute to self-stigma among patients. Promoting a sheltered experience in which isolation is used with respect for patients and the reasons are made explicit may encourage recovery. A shift in emphasis in ward culture from observation to engagement is needed to reduce blame, shift patient experiences from prison to shelter, and to support autonomy as a therapeutic intervention.

Effects of Seclusion and Restraint in Adult Psychiatry: A Systematic Review

Background: Determining the clinical effects of coercion is a difficult challenge, raising ethical, legal, and methodological questions. Despite limited scientific evidence on effectiveness, coercive measures are frequently used, especially in psychiatry. This systematic review aims to search for effects of seclusion and restraint on psychiatric inpatients with wider inclusion of outcomes and study designs than former reviews. Methods: A systematic search was conducted following PRISMA guidelines, primarily through Pubmed, Embase, and CENTRAL. Interventional and prospective observational studies on effects of seclusion and restraint on psychiatric inpatients were included. Main search keywords were restraint, seclusion, psychiatry, effect, harm, efficiency, efficacy, effectiveness, and quality of life. Results: Thirty-five articles were included, out of 6,854 records. Studies on the effects of seclusion and restraint in adult psychiatry comprise a wide range of outcomes and designs. The identified literature provides some evidence that seclusion and restraint have deleterious physical or psychological consequences. Estimation of post-traumatic stress disorder incidence after intervention varies from 25% to 47% and, thus, is not negligible, especially for patients with past traumatic experiences. Subjective perception has high interindividual variability, mostly associated with negative emotions. Effectiveness and adverse effects of seclusion and restraint seem to be similar. Compared to other coercive measures (notably forced medication), seclusion seems to be better accepted, while restraint seems to be less tolerated, possibly because of the perception of seclusion as "non-invasive." Therapeutic interaction appears to have a positive influence on coercion perception. Conclusion: Heterogeneity of the included studies limited drawing clear conclusions, but the main results identified show negative effects of seclusion and restraint. These interventions should be used with caution and as a last resort. Patients' preferences should be taken into account when deciding to apply these measures. The therapeutic relationship could be a focus for improvement of effects and subjective perception of coercion. In terms of methodology, studying coercive measures remains difficult but, in the context of current research on coercion reduction, is needed to provide workable baseline data and potential targets for interventions. Well-conducted prospective cohort studies could be more feasible than randomized controlled trials for interventional studies.

Exploring the Potential Psychiatric Implications of Astronomical Phenomena

Objective: Our study evaluates the potential psychiatric impact of the full phase of the moon on patients in a state psychiatric hospital in Buffalo, New York, between September 2013 and July 2018. Methods: This relationship is presented as the average number of restraints or seclusions (R&S) and code green psychiatric emergencies (CG) recorded 14 days before and 14 days after a full moon. Since the timeframe of the analysis included the August 21, 2017, solar eclipse, we also highlight the correlation between a partial solar eclipse and the number of CG events. We also compared full moon phase effects in 2017 to other years to benchmark whether the solar eclipse appeared to influence behavioral effects from baseline. Results: While there was a slight decrease in mean R&S on days where there was a full moon or in the month of a partial solar eclipse, the results were not considered to be significant or associated with human behavior. Conclusion: There was no real association between lunar and solar behavior and the actions of patients with psychiatric disorders.

Text Analysis of Electronic Medical Records to Predict Seclusion in Psychiatric Wards: Proof of Concept

Aim: With the introduction of "Electronic Medical Record" (EMR) a wealth of digital data has become available. This provides a unique opportunity for exploring precedents for seclusion. This study explored the feasibility of text mining analysis in the EMR to eventually help reduce the use of seclusion in psychiatry. Methods: The texts in notes and reports of the EMR during 5 years on an acute and non-acute psychiatric ward were analyzed using a text mining application. A period of 14 days was selected before seclusion or for non-secluded patients, before discharge. The resulting concepts were analyzed using chi-square tests to assess which concepts had a significant higher or lower frequency than expected in the "seclusion" and "non-seclusion" categories. Results: Text mining led to an overview of 1,500 meaningful concepts. In the 14 day period prior to the event, 115 of these concepts had a significantly higher frequency in the seclusion category and 49 in the non-seclusion category. Analysis of the concepts from days 14 to 7 resulted in 54 concepts with a significantly higher frequency in the seclusion-category and 14 in the non-seclusion category. Conclusions: The resulting significant concepts are comparable to reasons for seclusion in literature. These results are "proof of concept". Analyzing text of reports in the EMR seems therefore promising as contribution to tools available for the prediction of seclusion. The next step is to build, train and test a model, before text mining can be part of an evidence-based clinical decision making tool.

Physical Harm and Death in the Context of Coercive Measures in Psychiatric Patients: A Systematic Review

Background: For centuries coercive measures in psychiatry have been means of averting acute danger. It has been known for almost as long that these measures can lead to harm or even death to those affected. Over the past two decades the topic has increasingly been the subject of scientific discussion and research. While the legal and ethical preconditions for coercive measures in psychiatry as well as epidemiological studies on their incidence and patients' subjective experiences have increasingly come into focus, research on possible adverse events has lagged behind. To our knowledge there is no systematic review on the harmful or even fatal physical adverse effects of coercive interventions in psychiatry. Methods: We searched the databases PubMed and CINAHL for primary literature with a search string based on the PICO framework including key words describing different psychiatric diagnoses, coercive measures, and harms. Results: In total, 67 eligible studies (mainly case reports and case series) of very heterogeneous quality were included. Two RCTs were found reporting position-dependent cardiac deterioration, but were, however, carried out with healthy people and were characterized by a small number of cases. Death was the most frequently reported harm: cardiac arrest by chest compression in 14 studies, cardiac arrest by strangulation in 9, and pulmonary embolism in 8 studies. Further harms were, among others, venous thromboembolism and injuries. Injuries during physical restraint were reported in 0.8-4% of cases. For other kinds of coercive interventions, there are no sufficient data. Venous thromboembolism occurred in a considerable percentage of cases during mechanical restraint, also under prophylaxis. The most commonly reported coercive measure was restraint, distinguishing in mechanical restraint (43 studies), physical restraint (22 studies), bedrails (eight studies), vest restraint (7 studies), and chair restraint (6 studies). Forced medication was explicitly mentioned only in two, but seems to have occurred in nine studies. Six studies included seclusion. Conclusion: Coercive measures can lead to physical harm or even death. However, there is a significant lack of data on the incidence of such adverse events related to coercive interventions. Though reported anecdotally, physical adverse events during seclusion appear to be highly underresearched.

What factors influence the decisions of mental health professionals to release service users from seclusion?

Mental health policy stipulates seclusion should only be used as an intervention of last resort and for the minimum possible duration. Current evidence details which service users are more likely to be secluded, why they are secluded, and what influences the decision to seclude them. However, very little is known about the decision to release service users from seclusion. An integrative review was undertaken to explore the decision-making processes of mental health professionals which guide the ending of seclusion. The review used a systematic approach to gather and thematically analyse evidence within a framework approach. The twelve articles identified generated one overriding theme, maintaining safety. In addition, several subthemes emerged including the process of risk assessing which was dependent upon interaction and control, mediated by factors external to the service user such as the attitude and experience of staff and the acuity of the environment. Service users were expected to demonstrate compliance with the process ultimately ending in release and reflection. Little evidence exists regarding factors influencing mental health professionals in decisions to release service users from seclusion. There is no evidence-based risk assessment tool, and service users are not routinely involved in the decision to release them. Support from experienced professionals is vital to ensure timely release from seclusion. Greater insight into influences upon decisions to discontinue episodes may support initiatives aimed at reducing durations and use of seclusion.

[UHSI in the somatic care system for prisoners]

Inter-regional secure hospital units have noted an increase in the complex pathologies and care load of detained patients they receive for somatic care in a short-stay scheduled hospitalisation. Communication between health care providers and prison staff is essential for the proper functioning of these closed units. Transmissions with level 1 health units are essential to ensure continuity of care upon the patient's return to custody.

Single Rooms, Seclusion and the Non-Restraint Movement in British Asylums, 1838-1844

This article shows how the practice of seclusion-the confinement of asylum patients in locked rooms alone-entered the spotlight during the bitter controversy over the abolition of mechanical restraints in the late 1830s and early 1840s. Drawing on letters to The Lancet, asylum reports, reports of the Commissioners in Lunacy and polemical pamphlets, and focusing on the two asylums at the centre of the controversy, Lincoln and Hanwell, the article sets out the range of positions taken, from pro-restraint and anti-seclusion to anti-restraint and pro-seclusion. It shows how seclusion was associated with a lack of transparency, how it was seen as parallel to the disputed practice of solitary confinement in the prison system and how both the practice of seclusion and the single room itself were modified in the face of these challenges. John Conolly emerges as the most committed proponent of seclusion.

[The latest best practice guidelines relating to seclusion and restraint]

Several measures relating to seclusion and restraint are included in the French public health code. The best practice guidelines of the French National Health Authority, published in 2017, define these two notions and advise on the behaviour to adopt with regard to their implementation and monitoring. Likewise, informing and supporting the patient when these measures are lifted are critical moments which the teams must also be able to manage correctly.

Fear and blame in mental health nurses' accounts of restrictive practices: Implications for the elimination of seclusion and restraint

Restrictive practices continue to be used in mental health care despite increasing recognition of their harms and an international effort to reduce and ultimately eliminate their use. The aim of this qualitative study was to explore mental health nurses' views of the potential elimination of these practices. Nine focus groups were conducted with 44 mental health nurses across Australia, and the data analysed using thematic analysis. Overall, the nurses expressed significant fear about the potential elimination of restrictive practices and saw themselves as being blamed for both the use of these practices and the consequences should they be eliminated. Findings detail the conflicts facing staff in balancing the need for ward safety for everyone present while at the same time providing person-centred care. Nurses described the changing role of the mental health nurse in acute settings, being more focussed on risk assessment and medication while at the same time attempting to practise in trauma-informed person-centred ways. The impact on ward safety with increasing acuity of consumers plus the presence of forensic consumers and those affected by methamphetamine was emphasized. Change initiatives need to take into account nurses' deep concerns about the consequences of eliminating all forms of control measures in hospitals and respond to the symptoms and behaviours consumers present with and associated unpredictable and concerning behaviours. Attempts to eliminate restrictive practices should, therefore, be carefully considered and come with a clear articulation of alternatives to ensure the safety of consumers, visitors, and staff.

Factors associated with the use of seclusion in an inpatient psychiatric unit in Lilongwe, Malawi

Background

Data on the use of seclusion for psychiatric inpatients in sub-Saharan Africa are extremely limited. Though seclusion is sometimes necessary for patients that pose a threat to themselves or others, adverse physical and psychological sequelae from the experience are increasingly being recognized, leading to efforts to reduce its use. The purpose of this study was to calculate the frequency of seclusion in patients hospitalized in an inpatient psychiatric unit in Lilongwe, Malawi, and to identify factors associated with its use.

Methods

Records of 419 psychiatric inpatients hospitalized at Kamuzu Central Hospital's Bwaila Psychiatric Unit in Lilongwe, Malawi, from January 1, 2011 to December 31, 2011, were reviewed. Multivariate logistic regression analysis was employed to identify factors associated with the use of seclusion.

Results

Seclusion was used for 30.3% (127/419) of patients during the study period. Male patients had increased odds of being secluded (aOR: 2.22, p=0.02). Assaulting other patients on the unit (aOR 7.92, p<0.01) and presenting to the unit in mechanical restraints (aOR 2.33, p<0.01) were also associated with seclusion. There was no association between seclusion and age; diagnosis of alcohol use disorder, marijuana use disorder, or schizophrenia; involuntary admission; presence of extra pyramidal side effects; presence of hallucinations; suicidality; or commission of violent acts prior to admission.

Conclusions

Documentation about the rationale for the use of seclusion on the unit was minimal. Improved record keeping requirements will be essential to future efforts to study seclusion and reduce its use. Development of strategies to address patient violence on the unit could decrease the use of seclusion for aggressive patients. Patients arriving to the unit in restraints would benefit from increased efforts by staff to apply behavioural interventions or administer medications, in order to deescalate these individuals and limit the use of seclusion in their treatment.

Safeguarding Rights to Liberty and Security where People with Disability are Subject to Detention and Restraint: A Practical Approach to the Adjudication, Interpretation and Making of Law (Part Two)

This is the second article in a two-part series that establishes a framework for evaluating law as it affects the rights to liberty and security for people with intellectual and cognitive impairments. This article uses the rights-based approach developed in the first article to establish a methodology to evaluate the range of ways in which law can be made or interpreted in this area. The methodology considers the adjudication of common law rights by courts, judicial interpretation of statute and the making of laws. Key areas of law considered are those that permit the detention and use of restrictive practices for 'challenging behaviours' or 'behaviours of concern'. The article concludes by arguing that a rights-based approach and a method to assess how law applies it is essential to ensure that a 'thick' rule of law can protect and promote the rights and interests of people with intellectual and cognitive impairments.

Psychological assessment of acute schizophrenia patients who experienced seclusion either alone or in combination with restraint

Objective Numerous studies on the effects of seclusion and/or restraint in acute psychiatric treatment have reported both positive and negative effects. However, no studies to date have evaluated the effects of seclusion and/or restraint on schizophrenia patients using a rating scale. Thus, to examine the effects of seclusion and/or restraint on schizophrenia patients, we used the Brief Psychiatric Rating Scale and assessed the psychological condition of patients. Methods Factor analysis was conducted to create subscales of Brief Psychiatric Rating Scale, and psychiatric changes were assessed with respect to each subscale using multiple logistic regression analyses. Analyses were performed on three groups (i.e. entire, higher functioning, and lower functioning groups) involving a total of 1559 schizophrenia patients aged 18 to 65 years. Results In the entire and lower functioning groups, seclusion was a significant predictor of improvements related to the "hostility/suspiciousness" subscale. Seclusion combined with restraint was associated with improvements related to the "psychosis/thinking disorder" subscale. In the higher functioning group, there were no significant predictors. Conclusions It is implied that seclusion and/or restraint is related to improved psychiatric symptoms only among patients whose functioning is impaired. To verify the present findings, further studies involving multiple sites and additional psychiatric measures are necessary.

A pilot study of "post-seclusion and/or restraint review" intervention with patients and staff in a mental health setting

PURPOSE

To develop and evaluate a "post-seclusion and/or restraint review" (PSRR) intervention implemented in an acute psychiatric care unit.

DESIGN AND METHODS

Twelve staff members and three patients were enrolled in a participatory case study. To evaluate PSRR intervention, qualitative analysis was carried out. Seclusion and restraint use 6 months before and after the PSRR implementation was compared.

FINDINGS

Nurses reported that they were able to explore the patient's feelings during the PSRR intervention with patients, which led to restoration of the therapeutic relationship. PSRR with the treatment team was perceived as a learning opportunity, which allowed to improve the therapeutic intervention. Both the use of seclusion and the time spent in seclusion were significantly reduced 6 months after the implementation of PSRR intervention.

PRACTICE IMPLICATION

Our results suggest the efficacy of PSRR in overcoming the discomfort perceived by both staff and patient and, in the meantime, in reducing the need for coercive procedures. Systematic PSRR could permit to improve the quality of care and the safety of aggressiveness management.

Variables Associated With the Subjective Experience of Coercive Measures in Psychiatric Inpatients: A Systematic Review

OBJECTIVE

This systematic review presents evidence regarding factors that may influence the patient's subjective experience of an episode of mechanical restraint, seclusion, or forced administration of medication.

METHOD

Two authors searched CINAHL, PubMed, SCOPUS, Web of Science, and Psych-Info, considering published studies between 1 January 1992 and 1 February 2016. Based on the inclusion criteria and methodological quality, 34 studies were selected, reporting a total sample of 1,869 participants.

RESULTS

The results showed that the provision of information, contact and interaction with staff, and adequate communication with professionals are factors that influence the subjective experience of these measures. Humane treatment, respect, and staff support are also associated with a better experience, and debriefing is an important procedure/technique to reduce the emotional impact of these measures. Likewise, the quality of the working and physical environment and some individual and treatment variables were related to the experience of these measures. There are different results in relation to the most frequently associated experiences and, despite some data that indicate positive experiences, the evidence shows such experiences to be predominantly negative and frequently with adverse consequences. It seems that patients find forced medication and seclusion to be more tolerable than mechanical restraint and combined measures.

CONCLUSIONS

It appears that the role of the staff and the environmental conditions, which are potentially modifiable, affect the subjective experience of these measures. There was considerable heterogeneity among studies in terms of coercive measures experienced by participants and study designs.

Case study: design may influence use of seclusion and restraint

OBJECTIVE

The psychiatric emergency room is a dynamic and sometimes volatile environment. Its design may be an important variable in patient care, but most design decisions are based on models of thought and treatment with a minimal evidence base.

BACKGROUND

The concept of open design, increasing access of patients to nursing staff, for inpatient psychiatric units has recently gained widespread acceptance, despite a dearth of empirical data.

METHODS

We examined rates of seclusion and restraint before and after a design change that reduced the openness of the unit in a dedicated emergency psychiatric service in a general university hospital. Quality assurance data regarding the census, occurrence of assaults, and the use of seclusion and restraint were queried. Two independent analyses utilizing a test of proportional data were performed to replicate the findings.

RESULTS

After placement of a door to restrict patients' access to the waiting area of the unit, the rate of the use of seclusion and restraint went from 0.03 (44/777) to 0.0185 (27/1,514; z = 2.02, p < .04). Replication over a separate time period saw reduction from 0.029 (67/2,277) to 0.018 (44/2,431), z = 2.44, p < .02).

CONCLUSION

A design change that reduced the openness of the unit resulted in the reduction of seclusion and restraint.

Machine Learning: An Approach in Identifying Risk Factors for Coercion Compared to Binary Logistic Regression

Introduction: Although knowledge about negative effects of coercive measures in psychiatry exists, its prevalence is still high in clinical routine. This study aimed at define risk factors and test machine learning algorithms for their accuracy in the prediction of the risk to being subjected to coercive measures. Methods: In a sample of involuntarily hospitalized patients (n = 393) at the University Hospital of Psychiatry Zurich, we analyzed risk factors for the experience of coercion (n = 170 patients) using chi-square tests and Mann Whitney U tests. We trained machine learning algorithms [logistic regression, Supported Vector Machine (SVM), and decision trees] with these risk factors and tested obtained models for their accuracy via five-fold cross validation. To verify the results we compared them to binary logistic regression. Results: In a model with 8 risk-factors which were available at admission, the SVM algorithm identified 102 out of 170 patients, which had experienced coercion and 174 out of 223 patients without coercion (69% accuracy with 60% sensitivity and 78% specificity, AUC 0.74). In a model with 18 risk-factors, available after discharge, the logistic regression algorithm identified 121 out of 170 with and 176 out of 223 without coercion (75% accuracy, 71% sensitivity, and 79% specificity, AUC 0.82). Discussion: Incorporating both clinical and demographic variables can help to estimate the risk of experiencing coercion for psychiatric patients. This study could show that trained machine learning algorithms are comparable to binary logistic regression and can reach a good or even excellent area under the curve (AUC) in the prediction of the outcome coercion/no coercion when cross validation is used. Due to the better generalizability machine learning is a promising approach for further studies, especially when more variables are analyzed. More detailed knowledge about individual risk factors may help to prevent the occurrence of situations involving coercion.

East London Modified-Broset as Decision-Making Tool to Predict Seclusion in Psychiatric Intensive Care Units

Seclusion is a last resort intervention for management of aggressive behavior in psychiatric settings. There is no current objective and practical decision-making instrument for seclusion use on psychiatric wards. Our aim was to test the predictive and discriminatory characteristics of the East London Modified-Broset (ELMB), to delineate its decision-making profile for seclusion of adult psychiatric patients, and second to benchmark it against the psychometric properties of the Broset Violence Checklist (BVC). ELMB, an 8-item modified version of the 6-item BVC, was retrospectively employed to evaluate the seclusion decision-making process on two Psychiatric Intensive Care Units (patients n = 201; incidents n = 2,187). Data analyses were carried out using multivariate regression and Receiver Operating Characteristic (ROC) curves. Predictors of seclusion were: physical violence toward staff/patients OR = 24.2; non-compliance with PRN (pro re nata) medications OR = 9.8; and damage to hospital property OR = 2.9. ROC analyses indicated that ELMB was significantly more accurate that BVC, with higher sensitivity, specificity, and positive likelihood ratio. Results were similar across gender. The ELMB is a sensitive and specific instrument that can be used to guide the decision-making process when implementing seclusion.

De-escalation techniques used, and reasons for seclusion and restraint, in a forensic psychiatric hospital

In Finland, the Mental Health Act determines the legal basis for seclusion and restraint. Restrictive measures are implemented to manage challenging situations and should be used as a last resort in psychiatric inpatient care. In the present study, we examined the reasons for seclusion and restraint, as well as whether any de-escalation techniques were used to help patients calm down. Seclusion and restraint files from a 4-year period (1 June 2009-31 May 2013) were retrospectively investigated and analysed by content analysis. Descriptive statistics were calculated. A total of 144 episodes of seclusion and restraint were included to analyse the reasons for seclusion and restraint, and 113 episodes were analysed to examine unsuccessful de-escalation techniques. The most commonly-used techniques were one-to-one interaction with a patient (n = 74, 65.5% of n = 113) and administration of extra medication (n = 37, 32.7% of n = 113). The reasons for seclusion and restraint were threatening harmful behaviour (n = 51, 35.4% of n = 144), direct harmful behaviour (n = 43, 29.9%), indirect harmful behaviour (n = 42, 29.1%), and other behaviours (n = 8, 5.6%). In general, the same de-escalation techniques were used with most patients. Most episodes of seclusion or restraint were due to threats of violence or direct violence. Individual means of self-regulation and patient guidance on these techniques are needed. Additionally, staff should be educated on a diverse range of de-escalation techniques. Future studies should focus on examining de-escalation techniques for the prevention of seclusion.

Attitudes towards seclusion and restraint in mental health settings: findings from a large, community-based survey of consumers, carers and mental health professionals

AIMS

There are growing calls to reduce, and where possible eliminate, the use of seclusion and restraint in mental health settings, but the attitudes and beliefs of consumers, carers and mental health professionals towards these practices are not well understood. The aim of this study was to compare the attitudes of mental health service consumers, carers and mental health professionals towards seclusion and restraint in mental health settings. In particular, it aimed to explore beliefs regarding whether elimination of seclusion and restraint was desirable and possible.

METHODS

In 2014, an online survey was developed and widely advertised in Australia via the National Mental Health Commission and through mental health networks. The survey adopted a mixed-methods design, including both quantitative and qualitative questions concerning participants' demographic details, the use of seclusion and restraint in practice and their views on strategies for reducing and eliminating these practices.

RESULTS

In total 1150 survey responses were analysed. A large majority of participants believed that seclusion and restraint practices were likely to cause harm, breach human rights, compromise trust and potentially cause or trigger past trauma. Consumers were more likely than professionals to view these practices as harmful. The vast majority of participants believed that it was both desirable and feasible to eliminate mechanical restraint. Many participants, particularly professionals, believed that seclusion and some forms of restraint were likely to produce some benefits, including increasing consumer safety, increasing the safety of staff and others and setting behavioural boundaries.

CONCLUSIONS

There was strong agreement across participant groups that the use of seclusion and restraint is harmful, breaches human rights and compromises the therapeutic relationship and trust between mental health service providers and those who experience these restrictive practices. However, some benefits were also identified, particularly by professionals. Participants had mixed views regarding the feasibility and desirability of eliminating these practices.

Associations between psychiatric symptoms and seclusion use: Clinical implications for care planning

Findings from an increasing number of studies suggest that incorporating systematic short-term risk assessments in treatment planning could lead to safer practice on psychiatric admissions wards. The aim of the present study was to investigate the associations between the scores of three structured observation tools - the Kennedy Axis V (K-Axis-V), the Brief Psychiatric Rating Scale (BPRS), and the Social Dysfunction and Aggression Scale (SDAS) - and seclusion. In total, 1840 weekly risk assessments with these observation scales were collected over 2342 admission weeks. These assessment scores related to 370 acutely-admitted psychiatric patients and were subjected to a multilevel analysis. It was found that several dynamic and static factors were related to seclusion. Dynamic factors included violent behaviour, current substance abuse, suspiciousness, and negativism. Static factors included ethnicity and having been diagnosed with a substance abuse disorder. The findings suggest that the incorporation of the Kennedy-Axis V, the BPRS, and the SDAS into standard practice might be helpful in identifying patients at high risk of seclusion, and could be supportive to treatment planning and clinical decision-making in the prevention of seclusion use in acute psychiatric settings.

Outcomes of the Victorian Safewards trial in 13 wards: Impact on seclusion rates and fidelity measurement

Restrictive practices are used in response to conflict and aggression in psychiatric inpatient settings. Reducing such practices is the focus internationally of policy and legislative change, many initiatives, and a growing body of research. Safewards is a model and a set of 10 interventions designed to reduce conflict and containment in inpatient services. In the current study, we aimed to assess the impact of implementing Safewards on seclusion in Victorian inpatient mental health services in Australia. The study used a before-and-after design, with a comparison group matched for service type. Thirteen wards opted into a 12-week trial to implement Safewards and 1-year follow up. The comparison group was all other wards (n = 31) with seclusion facilities in the jurisdiction, matched to service type. Mandatorily-reported seclusion event data for all 44 wards over a 15-month period were analysed using negative binomial regression. Adherence to Safewards was measured via fidelity checklists at four time points: twice during the trial, post-trial, and at 1-year follow up. Seclusion rates were reduced by 36% in Safewards trial wards by the 12-month follow-up period (incidence rate ratios (IRR) = 0.64,) but in the comparison wards seclusion rates did not differ from baseline to post-trial (IRR = 1.17) or to follow-up period (IRR = 1.35). Fidelity analysis revealed a trajectory of increased use of Safewards interventions after the trial phase to follow up. The findings suggest that Safewards is appropriate for practice change in Victorian inpatient mental health services more broadly than adult acute wards, and is effective in reducing the use of seclusion.

Prolonged use of seclusion and mechanical restraint in mental health services: A statewide retrospective cohort study

Seclusion and mechanical restraint are restrictive interventions that should be used only as a last resort and for the shortest possible time, yet little is known about duration of use in the broader context. Adult area mental health services throughout Victoria, Australia, were asked to complete a report form for prolonged episodes of seclusion (>8 hours) and mechanical restraint (>1 hour). The present, retrospective cohort study aimed to understand the individual (age, sex, type of service, duration of intervention) and contextual factors associated with prolonged use of restrictive interventions. Contextual factors describing the reasons for prolonged use of the restrictive interventions were captured qualitatively, and then coded using content analysis. Median duration was compared across individual factors using Mann-Whitney U-tests. During 2014, 690 episodes of prolonged restrictive intervention involving 311 consumers were reported. Close to half (n = 320, 46%) involved mechanical restraint. Seclusion episodes (n = 370) were longer in forensic mental health services compared to adult area mental health services (median: 24 hours and 18 min vs 16 hours and 42 min, P < 0.001). Mechanical restraint episodes (n = 320) were shorter in forensic mental health services compared to adult area mental health services (median: 3 hours and 25 min vs 4 hours and 15 min, P = 0.008). Some consumers were subject to multiple episodes of prolonged seclusion (55/206, 27%) and/or prolonged mechanical restraint (31/131, 24%). The most commonly occurring contextual factor for prolonged restrictive interventions was 'risk of harm to others'. Means for reducing the use of prolonged restrictive interventions are discussed in light of the findings.

Multidimensional approach to restraint minimization: The journey of a specialized mental health organization

The executive-level witnessing and review of restraint events has been identified as a key strategy for restraint minimization. In the present study, we examined the changes in restraint practices at a tertiary-level mental health-care facility with implementation of an initiative, in which representatives from senior management, professional practice, peer support, and clinical ethics witnessed seclusion and restraint events, and rounded with clinical teams to discuss timely release and brainstorm prevention strategies. Interrupted time series analysis compared the change from pre-implementation (14 months prior) to postimplementation (35 months' following) in the number of incidents/month, total hours/month, and average hours/incident/month for each of seclusion and mechanical restraint. With implementation, there was a step decrease in average hours/seclusion (-28.3 hours/seclusion, P < 0.001) and total seclusion hours (-1264.5 hours, P = 0.002). The postimplementation rate of decrease of -0.9 hours/incident/month was different than the pre-implementation rate of increase of 0.7 hours/incident/month for mechanical restraint (P = 0.03). Pre-implementation, there was a rate of decrease of 6.1 incidents/month (P < 0.001) and 4.5 incidents/month (P = 0.001) for seclusion and mechanical restraint, respectively. Postimplementation, there was a rate of increase of 0.3 incidents/month and a rate of decrease of 0.05 incidents/month for seclusion and mechanical restraint, respectively, both of which were different than pre-implementation (seclusion: P < 0.001, mechanical restraint: P = 0.002). In conclusion, the total hours of seclusion and average hours per seclusion and per restraint incident were reduced, demonstrating the value of leadership witnessing and daily rounds in promoting restraint minimization in tertiary-level mental health care.

Who experiences seclusion? An examination of demographics and duration in a public acute inpatient mental health service

Restrictive interventions such as seclusion may occur during an acute mental health crisis. Such interventions are experienced by people as traumatic and counter to recovery. The current study aimed to investigate the use of seclusion and who was secluded amongst patients presenting with psychotic symptomology. All acute inpatient admissions were examined across a 12-month period January-December 2013. Electronic and paper records were accessed and audited for all 655 admissions. There were 91 admissions that included a seclusion and 200 seclusion events. There were 79 unique patients who experienced seclusion. For those experiencing seclusion: two-thirds were male, 49% were either homeless or had no fixed abode, 32% received case management in the community prior to their inpatient stay, and 56% were unemployed or not in the workforce. The median and mode duration of seclusion was 4 h. By understanding seclusion interventions better, changes can be made to enhance practice. This descriptive research into seclusion has clarified the demographics of who is most likely to experience seclusion, for how long, and the implications for reducing restrictive interventions. How the social work role could contribute to reforms to protect and enhance the rights and well-being of marginalized members of our communities, at their most vulnerable, is considered.

Six years of national mental health seclusion data: the Australian experience

OBJECTIVES

Reducing or eliminating seclusion from mental health care settings has been a national priority for Australia since 2005. This paper describes Australia's national seclusion data collection, and summarises changes in seclusion rates in Australian public mental health services.

METHODS

Seclusion events per 1000 patient days were calculated from 2009-2010 to 2014-2015 utilising state and territory administrative data sources. Combined national data were used to calculate results for a number of service characteristics, such as target population and location of the service.

RESULTS

The rate of seclusion events decreased by 43% over the 6 years. Child and adolescent services reported consistently higher rates of seclusion, but a shorter duration of seclusion episodes, compared with other service types. There is high variation in seclusion rates between individual services (range 0.0-53.0 seclusion events per 1000 bed days in 2014-2015).

CONCLUSIONS

Seclusion event rates in Australia's specialised public acute mental health hospital services are declining. The use of existing administrative data was instrumental in establishing a national data source to facilitate the monitoring and reporting of progress of seclusion reduction strategies.

Association of methamphetamine use and restrictive interventions in an acute adult inpatient mental health unit: A retrospective cohort study

The aim of the present study was to describe incidences of restrictive interventions and the association of methamphetamine use at an acute adult inpatient mental health unit in metropolitan Melbourne, Victoria, Australia. A total of 232 consecutive consumer admissions to the inpatient unit across a 3-month period were described for illicit substance use and the use of restrictive interventions (seclusion, mechanical restraint, and physical restraint) prior to and during admission. Of all admissions, 25 (10.8%) involved consumers subjected to a restrictive intervention. Methamphetamine use was either self-reported or detected by saliva test for 71 (30.6%) consumers. Following multivariate analyses, methamphetamine use (odds ratio (OR): 7.83, 95% confidence interval (CI): 2.33-26.31) and restrictive intervention in the emergency department prior to admission (OR: 8.85, 95% CI: 2.83-27.70) were significant independent predictors of the use of restrictive interventions after inpatient admission. Anecdotal observations provided by clinical mental health staff that consumers intoxicated with methamphetamine appear to require restrictive intervention more frequently than other consumers was confirmed with the results of the current study. As the state of Victoria in Australia is on a pathway to the elimination of the use of restrictive interventions in mental health services, clinicians need to develop management strategies that provide specialist mental health care using the least-restrictive interventions. Although 26.8% of methamphetamine users were secluded after admission, restrictive interventions should not be the default management strategy for consumers who present with self-report or positive screen for methamphetamine use.

Acceptability and use of coercive methods across differing service configurations with and without seclusion and/or psychiatric intensive care units

Aims

The aim of this study was to compare across different service configurations the acceptability of containment methods to acute ward staff and the speed of initiation of manual restraint.

Background

One of the primary remits of acute inpatient psychiatric care is the reduction in risks. Where risks are higher than normal, patients can be transferred to a psychiatric intensive care unit or placed in seclusion. The abolition or reduction in these two containment methods in some hospitals may trigger compensatory increases in other forms of containment which have potential risks. How staff members manage risk without access to these facilities has not been systematically studied.

Design

The study applied a cross‐sectional design.

Methods

Data were collected from 207 staff at eight hospital sites in England between 2013 ‐ 2014. Participants completed two measures; the first assessing the acceptability of different forms of containment for disturbed behaviour and the second assessing decision‐making in relation to the need for manual restraint of an aggressive patient.

Results

In service configurations with access to seclusion, staff rated seclusion as more acceptable and reported greater use of it. Psychiatric intensive care unit acceptability and use were not associated with its provision. Where there was no access to seclusion, staff were slower to initiate restraint. There was no relationship between acceptability of manual restraint and its initiation.

Conclusion

Tolerance of higher risk before initiating restraint was evident in wards without seclusion units. Ease of access to psychiatric intensive care units makes little difference to restraint thresholds or judgements of containment acceptability.