Strategies to reduce the use of seclusion with tāngata whai i te ora (Māori mental health service users)

Māori, the indigenous people of New Zealand, have the highest crude population-based rate of seclusion events reported internationally (McLeod et al. ). This qualitative study explored Māori clinical, cultural and consumer perspectives on potential strategies and initiatives considered likely to facilitate prevention of, and reduction in, the use of seclusion, with tāngata whai i te ora (Māori mental health service users) in mental health inpatient services. A hui (gathering) over 2 days was held with 16 Māori participants with high levels of clinical, cultural and consumer expertise. The gathering was taped and the tapes transcribed. A thematic analysis of the hui data generated three key categories: Te Ao Māori (access to a Māori worldview); Te Ao Hurihuri (transforming practice); and Rangatiratanga (leadership, power, and control). The findings of this study align with the "six core strategies" for best practice to reduce the use of seclusion (Huckshorn ). A comprehensive approach to the reduction of the use of seclusion with tāngata whai i te ora is required, which is clearly based on a Māori model of care and a vision for transformation of practice in mental health inpatient services, which involves Māori leadership.

Acute mental health service delivery to Indigenous women: What is known?

The Australian College of Mental Health Nurses directs that mental health nurses must 'enable cultural safety in practice, taking into account age, gender, spirituality, ethnicity and health values'. The present study is a review of the existing literature undertaken in order to identify current knowledge and knowledge gaps regarding the experience of Indigenous women in acute mental health inpatient facilities. In particular, studies that identified environments and practices promoting the development of culturally-safe healing spaces for Indigenous women, and studies that identified women's experience of seclusion, were sought. The results showed that there is little literature directly relevant to Indigenous women's experiences of inpatient mental health units in Australia. The present study consolidates existing knowledge and knowledge gaps, and advances the argument for gender-disaggregated future research. Implications for professional practice and service development are also noted.

Involuntary Medication, Seclusion, and Restraint in German Psychiatric Hospitals after the Adoption of Legislation in 2013

BACKGROUND

Involuntary medication in psychiatric treatment of inpatients is highly controversial. While laws regulating involuntary medication have been changed in Germany, no data have been available to date on how often involuntary medication is actually applied. Recently, our hospital group introduced specific routine documentation of legal status and application of involuntary medication in the patients' electronic records, which allows the assessment of the frequency of involuntary medication.

METHOD

For the year 2014, we extracted aggregated data from the electronic database on age, sex, psychiatric diagnosis, legal status during admission, kind of coercive measure (mechanical restraint, seclusion, and involuntary medication) applied, and the number and duration of seclusion and restraint episodes for seven study sites.

RESULTS

A total of 1,514 (9.6%) of 15,832 admissions were involuntary. At least one coercive measure was applied in 976 (6.2%) admissions. Seclusion was applied in 579 (3.7%) admissions, mechanical restraint was applied in 529 (3.3%) admissions, and involuntary medication was applied in 78 (0.5%) admissions. Two-thirds of involuntary medications were applied in cases of emergency; the remainder was applied after a formal decision by a judge. In 55 (70.5%) of the admissions with involuntary medication, at least one other coercive measure (seclusion, restraint, or both) was applied as well.

CONCLUSION

Involuntary medication is rarely applied and less frequent than seclusion or mechanical restraint, possibly as a consequence of recent legal restrictions.

Limiting Patients as a Nursing Practice in Psychiatric Intensive Care Units to Ensure Safety and Gain Control

PURPOSE

The aim of this study was to describe how the limitation of patients is being practiced in psychiatric intensive care units.

DESIGN AND METHODS

A focused ethnographic methodology was applied. To gather data, the author conducted fieldwork involving participant observation.

FINDINGS

The results of the study are presented in two categories, which describe the limited access patients had to items and in the ward environments.

PRACTICE IMPLICATIONS

It is advisable for practitioners to critically reflect upon local regulations and policies related to the practice of limiting patients during the worst phase of their mental illness.

Recovery-based services in a psychiatric intensive care unit - the consumer perspective

OBJECTIVE

To describe the implementation of recovery-based practice into a psychiatric intensive care unit, and report change in seclusion rates over the period when these changes were introduced (2011-2013).

METHOD

Recovery-based practices including collaborative care, safety care plans, a comfort room, and debriefing after coercive interventions were introduced. A carer consultant was employed. A restraint and seclusion review committee, chaired by a peer worker, was established. A consumer exit interview was introduced and these data were collected, reviewed by staff and the peer worker and used to improve the ward environment. Rates of seclusion were measured during the period when recovery-based practices were introduced.

RESULTS

Consumer feedback indicated that positive aspects of the psychiatric intensive care unit included approachable, helpful staff and completion of a safety care plan. Negative aspects included lack of involvement in decisions about admission and about medications, the non-smoking policy, and being placed in seclusion or restraint. There was a significant reduction in the number of consumers secluded and the total number of seclusions.

CONCLUSIONS

Recovery principles can be successfully introduced in a psychiatric intensive care unit environment. Introduction of recovery based practice was associated with a reduction in seclusion.

Understanding Mental Health Service User Experiences of Restraint Through Debriefing: A Qualitative Analysis

OBJECTIVE

To examine debriefing data to understand experiences before, during, and after a restraint (seclusion, chemical, and physical) event from the perspective of inpatients at a large urban mental health and addiction hospital.

METHOD

Audits were conducted on a purposeful sample of inpatient charts containing post-restraint event inpatient debrief forms (n = 55). Qualitative data from the forms were analyzed thematically.

RESULTS

Loss of autonomy and related anger, conflict with staff and other inpatients, and unmet needs were the most common factors precipitating restraint events. Inpatients often reported that increased communication with staff could have prevented restraint. Inpatients described having had various negative emotional states and responses during restraint events, including fear and rejection. Post-restraint, inpatients often desired to leave the unit for fresh air or to engage in leisure activities.

CONCLUSIONS

To our knowledge, our study is the first to use debriefing form data to explore mental health inpatients' experiences of restraint. Inpatients view restraint negatively and do not experience it as a therapeutic intervention. Debriefing, guided by a form, is useful for understanding the inpatient's experience of restraint, and should be used to re-establish the therapeutic relationship and to inform plans of care. In addition, individual and collective inpatient perspectives should inform alternatives to restraint.

Seclusion as a necessary vs. an appropriate intervention: a vignette study among mental health nurses

In a vignette study, mental health nurses were asked to score vignettes on necessity and appropriateness using a Likert scale. Sixty-nine clinical nurses from four mental health institutes scored 64 vignettes on necessity (there is no alternative) and appropriateness (seclusion supports patients' treatment) of seclusion simultaneously. Data analysis focused on the differences between both scores, and included general linear model analysis, t-test statistics and Kendall's tau. The t-test resulted in a significantly higher score on necessity than on appropriateness. Differences between both scores could be explained for 32% by a combination of nurse characteristics and vignette variables. Necessity and appropriateness were found to be strongly associated with each other, showing that underpinning patterns were largely the same. This research enhances the understanding of underlying factors that influence the decision of nurses to use seclusion. This is essential for the development of interventions aimed at the reduction of seclusion use in mental health practice.

Nurses' experiences of restraint and seclusion use in short-stay acute old age psychiatry inpatient units: a qualitative study

Restraint and seclusion are often ineffective and can affect patients adversely. In this study, we explored nurses' experiences of restraint and seclusion in short-stay acute old age psychiatry inpatient units and how these experiences underpin resistance to eliminating these practices. Qualitative interviews were conducted with nurses in three old age psychiatry units in Melbourne, Australia. The results provide one overarching theme, lack of accessible alternatives to restraint and seclusion, indicating that nurses believe there are no effective, accessible alternatives to these practices. Three related themes contribute to this perception. First, an adverse interpersonal environment contributes to restraint and seclusion, which relates to undesirable consequences of poor staff-to-patient relationships. Second, an unfavourable physical environment contributes to aggression and restraint and seclusion use. Third, the practice environment influences the adoption of restraint and seclusion. The findings contribute to the limited evidence about nurses' experiences of these practices in short-stay old age psychiatry, and how account needs to be taken of these experiences and contextual influences when introducing measures to address these practices. Policies addressing these measures need to be accompanied by wide-ranging initiatives to deal with aggression, including providing appropriate education and support and addressing ethical and workplace cultural issues surrounding these practices.

When reduction strategies are put in place and mental health consumers are still secluded: an analysis of clinical and sociodemographic characteristics

Internationally, seclusion practices continue to be the subject of intense clinical health service and academic scrutiny. Despite extensive efforts to reduce and eliminate this controversial practice, seclusion remains a clinical intervention widely used in contemporary mental health service settings. Early identification of people who are at risk for seclusion and the timely application of alternative evidence-based interventions are critical for reducing incidents of seclusion in real-world practice settings. This retrospective study aimed to determine the relationship between sociodemographic and clinical characteristics, and the use of seclusion for those mental health consumers for whom evidence-based seclusion-reduction initiatives had little impact. A 12-month centred moving average was fitted to seclusion data from a psychiatric inpatient unit over 2 years to determine stabilization in seclusion reduction. The number of consumers admitted was calculated from the point of stabilization for 1 year (n = 469). In this cohort, univariate analysis sought to compare the characteristics of those who were secluded and those who were not. A multivariate logistic regression model was undertaken to associate future seclusion based on significant independent variables. Of those people admitted, 88 (19%) were secluded. The majority of seclusions occurred in the first 5 days (70/88, 79%). Multivariate logistic regression indicated that three variables maintained their independent associative risk of seclusion: (i) age less than 35 years; (ii) assessment of risk of violence to others; and (iii) a history of seclusion. The implications of these findings for nursing practice are discussed.

An organizational approach to reducing and preventing restraint and seclusion use with people with acquired brain injury

INTRODUCTION

Seclusion, restraint (S/R) and coercive practices are used across human service populations, settings, with people of all ages. Their use has been increasingly scrutinized by the public, federal government and the media. Alternatives, interventions, and organizational approaches to these forms of containment are now emerging and advancing practice.

AIM/PURPOSE

This article provides an overview of the work conducted to reduce the use of coercion restraint, seclusion and other invasive practices in behavioral health settings that often include the defacto admission of persons with Acquired Brain Injury (ABI). The article also examines treatment culture factors that can exacerbate behavior dysfunction and how to moderate such challenges to prevent the use of S/R procedures among people with ABI.

CONCLUSION

Seclusion and restraint can be avoided and greatly reduced in settings serving people with ABI. When S/R use is recognized as an inadequate organizational response to harmful behavior that maintains patterns of aggression or harm, leadership-driven core strategies can be implemented to disrupt the behavioral sequence. The Six Core Strategies© provide a prevention based framework to anticipate challenge, intervene early, and analyze the factors that contribute to maintaining the cycle of violence if S/R is used.

Nursing care process for releasing psychiatric inpatients from long-term seclusion in Japan: modified grounded theory approach

Based on a modified grounded theory approach, in this study, we sought to elucidate the nursing care process used to guide psychiatric inpatients in long-term seclusion towards release from seclusion. Participant observations and interviews were conducted with a total of 18 nurses from three long-term psychiatric wards at two institutions from September 2011 to November 2012, to collect data on the nursing care they provided for psychiatric patients in long-term seclusion. Consequently, four categories and 15 concepts were extracted. The nurses viewed "a mature therapeutic environment that utilizes flexible apportionment of care" as the foundation (i.e. the core category) in guiding psychiatric inpatients towards release from long-term seclusion. The results revealed a care structure in which nurses in such a treatment environment provided care by flexible apportionment of three types of care: care aimed at avoiding mental and physical exhaustion, standardized care that does not confer a disadvantage to patients, and immediately responding to prevent problematic behaviors.

The use of coercive interventions in mental health care in Germany and the Netherlands. A comparison of the developments in two neighboring countries

In this review, we compare the use of coercion in mental health care in Germany and in the Netherlands. Legal frameworks and published data on involuntary commitment, involuntary medication, seclusion, and restraint are highlighted as well as the role of guidelines, training, and attitudes held by psychiatrists and the public. Legal procedures regulating involuntary admission and commitment are rather similar, and so is the percentage of involuntary admissions and the rate per 100,000 inhabitants. However, opposing trends can be observed in the use of coercive interventions during treatment, which in both countries are considered as a last resort after all other alternative approaches have failed. In the Netherlands, for a long time seclusion has been considered as preferred intervention while the use of medication by force was widely disapproved as being unnecessarily invasive. However, after increasing evidence showed that number and duration of seclusions as well as the number of aggressive incidents per admission were considerably higher than in other European countries, attitudes changed within recent years. A national program with spending of 15 million € was launched to reduce the use of seclusion, while the use of medication was facilitated. A legislation is scheduled, which will allow also outpatient coercive treatment. In Germany, the latter was never legalized. While coercive treatment in Germany was rather common for involuntarily committed patients and mechanical restraint was preferred to seclusion in most hospital as a containment measure, the decisions of the Constitutional Court in 2011 had a high impact on legislation, attitudes, and clinical practice. Though since 2013 coercive medication is approvable again under strict conditions, it is now widely perceived as very invasive and last resort. There is evidence that this change of attitudes lead to a considerable increase of the use of seclusion and restraint for some patients.

Reducing seclusion and restraint during child and adolescent inpatient treatment: still an underdeveloped area of research

PROBLEM

Half of all youth hospitalized in inpatient psychiatric facilities manifest aggressive behavior. When aggression escalates to the point of danger, measures must be employed to guarantee safety of both patients and staff. In this paper, the current empirical evidence for intervention models to reduce restriction and restraint utilization in children and adolescents is reviewed.

METHOD

PubMed and PsycINFO were searched for English-language articles published between 2006 and 2013. Included were empirical studies of child or adolescent inpatient populations using a pretest and posttest design.

FINDING

Included in this review are three empirical papers describing two different intervention models that met the inclusion criteria.

CONCLUSIONS

The review indicates there are two empirical supported intervention models that are helpful in reducing seclusion and restraint utilization in children and adolescents. The promising empirical findings support evidence and application to the child/adolescent population for at least three of the six National Association of State Mental Health Program Directors core strategies for restraint reduction. The modest number of empirical papers reflects that reducing restrictive measures in child/adolescent inpatient treatment remains an underdeveloped area of research.

The use of restraint in four general hospital emergency departments in Australia

OBJECTIVE

The purpose of this study was to investigate restraint use in Australian emergency departments (EDs).

METHOD

A retrospective audit of restraint incidents in four EDs (from 1 January 2010 to 31 December 2011).

RESULTS

The restraint rate was 0.04% of total ED presentations. Males and females were involved in similar numbers of incidents. Over 90% of restrained patients had a mental illness diagnosis and were compulsorily hospitalised. Mechanical restraint with the use of soft shackles was the main method used. Restraint was enacted to prevent harm to self and/or others. Median incident duration was 2 hours 5 minutes.

CONCLUSIONS

In order to better integrate the needs of mental health clients, consideration is needed as to what improvements to procedures and the ED environment can be made. EDs should particularly focus on reducing restraint duration and the use of hard shackles.

Use of restrictive interventions in a child and adolescent inpatient unit - predictors of use and effect on patient outcomes

OBJECTIVES

Restrictive interventions (seclusion, physical restraint, and use of acute/p.r.n. sedation) may have negative effects on patients. Identifying factors associated with use of restrictive interventions and examining their effect on admission outcomes is important for optimising inpatient psychiatric care.

METHODS

This study documented use of restrictive interventions within a child and adolescent psychiatric inpatient unit for 15 months. Two models examined predictors of use of restrictive interventions: (i) incident characteristics; and (ii) patient characteristics. The relationship between use of restrictive interventions and global clinical outcomes was also examined.

RESULTS

Of 134 patients admitted during the study period (61.9% female, mean age=13.8±2.9 years), 26.9% received at least one restrictive intervention. Incident factors associated with restrictive interventions were: physical aggression, early admission stage, and occurrence in private space. Patient factors that predicted use of restrictive interventions were developmental disorder and younger age. Use of restrictive interventions was not associated with increased length of stay or diminished improvement in global symptom ratings.

CONCLUSIONS

Further research is needed to identify best practice in children at high risk for receiving restrictive interventions.

Reduction in the use of seclusion by the methodical work approach

Patient care in a psychiatric setting can benefit from a more systematic, transparent, and goal-driven way of working. The methodical work approach, with its cyclic five phases, provides such an approach: (i) translation of problems into goals; (ii) search for means to realize the goals; (iii) formulation of an individualized plan; (iv) implementation of the plan; and (v) evaluation and readjustment. We examined the effect of the methodical work approach on the use of seclusion at a ward for the intensive treatment of inpatients with psychoses and substance-use disorders. The team of this ward implemented the methodical work approach. Special attention was paid to the involvement of the patient and his/her family in the treatment process and to the role of the coordinating nurse. Compared to control wards within the same hospital, at the ward where the methodical work approach was implemented, a more pronounced reduction was achieved in the number of incidents and in the total hours of seclusion. Implementation of the methodical work approach can contribute to a reduction in the use of seclusion.

Attitudes of clinical staff toward the causes and management of aggression in acute old age psychiatry inpatient units

BACKGROUND

In psychiatry, most of the focus on patient aggression has been in adolescent and adult inpatient settings. This behaviour is also common in elderly people with mental illness, but little research has been conducted into this problem in old age psychiatry settings. The attitudes of clinical staff toward aggression may affect the way they manage this behaviour. The purpose of this study was to examine the attitudes of clinical staff toward the causes and management of aggression in acute old age psychiatry inpatient settings.

METHODS

A convenience sample of clinical staff were recruited from three locked acute old age psychiatry inpatient units in Melbourne, Australia. They completed the Management of Aggression and Violence Scale, which assessed the causes and managment of aggression in psychiatric settings.

RESULTS

Eighty-five staff completed the questionnaire, comprising registered nurses (61.1%, n = 52), enrolled nurses (27.1%, n = 23) and medical and allied health staff (11.8%, n = 10). A range of causative factors contributed to aggression. The respondents had a tendency to disagree that factors directly related to the patient contributed to this behaviour. They agreed patients were aggressive because of the environment they were in, other people contributed to them becoming aggressive, and patients from certain cultural groups were prone to these behaviours. However, there were mixed views about whether patient aggression could be prevented, and this type of behaviour took place because staff did not listen to patients. There was agreement medication was a valuable approach for the management of aggression, negotiation could be used more effectively in such challenging behaviour, and seclusion and physical restraint were sometimes used more than necessary. However, there was disagreement about whether the practice of secluding patients should be discontinued.

CONCLUSIONS

Aggression in acute old age psychiatry inpatient units occurs occasionally and is problematic. A range of causative factors contribute to the onset of this behaviour. Attitudes toward the management of aggression are complex and somewhat contradictory and can affect the way staff manage this behaviour; therefore, wide-ranging initiatives are needed to prevent and deal with this type of challenging behaviour.

Measuring the impacts of seclusion on psychiatry inpatients and the effectiveness of a pilot single-session post-seclusion counselling intervention

Despite the accumulation of evidence demonstrating patients' accounts of trauma associated with seclusion, the use of evidence-based post-seclusion debriefing is not apparent in the published work. This study aimed to identify the impacts seclusion has on an individual using the Impact of Events - Revised (IES-R), a standardized and widely used measure of trauma symptoms, and measure the effectiveness of a post-seclusion counselling intervention in mitigating the experience of seclusion-related trauma and reducing time spent in seclusion. The study design involved a comparison of the seclusion-related trauma and time in seclusion that was experienced by consenting patients managed on the two inpatient wards of Alfred Psychiatry. To investigate the efficacy of post-seclusion counselling to reduce event-related trauma as well as the use of seclusion, a brief single-session intervention was piloted comparing outcomes for patients treated on a ward implementing semistructured post-seclusion counselling and patients treated on a ward continuing with post-seclusion support as usual. A total of 31 patients consented to participate, with approximately 47% reporting trauma symptoms consistent with 'probable post-traumatic stress disorder' (IES-R total score, >33), although there was no difference in trauma experience between groups. Significantly fewer hours were spent in seclusion for patients treated on the ward piloting the post-seclusion counselling intervention. Findings, therefore, highlight not only the potential for significant trauma stemming from a seclusion event, but also the capacity for the implementation of such interventions as post-seclusion counselling to raise awareness of the need to minimize time spent in seclusion for patients.

Association between short-term structured risk assessment outcomes and seclusion

Research findings indicate that the symptoms and behaviour of acute psychiatric patients can fluctuate drastically within hours, and that structured daily risk assessments can reduce the risk of aggressive incidents and the duration of seclusion. The aim of this study was to investigate the validity of two structured observation tools, the Brøset Violence Checklist (BVC) and the Kennedy Axis V), as an aid in seclusion-related clinical decision-making. In this study, 7403 day-to-day risk assessments were collected over 10 725 admission days (72% of the maximum number of structured assessments). A total of 7055 daily assessment scores from 301 acute psychiatric patients were used for the multilevel analysis. The sample demonstrated that dynamic and static factors were related to seclusion. Dynamic factors included dysfunctional scores on the item 'confusion' of the Brøset Violence Checklist, and psychological impairment and impairment of social skills on the Kennedy Axis V. Static factors included non-Western descent, male sex, age less than 35 years, unmarried, and to some extent, a personality disorder. McFadden's pseudo R(2) value showed that most of the final model was related to the dynamic factors. We concluded that the incorporation of the BVC and the Kennedy Axis V into standard practice was helpful in identifying patients at high risk of seclusion.

'I sang Amazing Grace for about 3 hours that day': understanding Indigenous Australians' experience of seclusion

Research shows that Indigenous Australians' suspicion and fear of being 'locked up' may influence mental health service avoidance. Given this, the aim of this study was to explore, by qualitative analysis of in-depth interviews (n = 3), how three Indigenous people experienced the controversial practice of seclusion. Hans-Georg Gadamer's phenomenology guided analysis of the material, and allowed narrated experiences to be understood within their cultural and historical context. Participants viewed seclusion negatively: police involvement in psychiatric care; perceptions of being punished and powerless; occasions of extreme use of force; and lack of care were prominent themes throughout the interviews. While power imbalances inherent in seclusion are problematic for all mental health clients, the distinguishing factor in the Indigenous clients' experience is that seclusion is continuous with the discriminatory and degrading treatment by governments, police, and health services that many Indigenous people have experienced since colonization. The participants' experiences echoed Goffman's findings that institutional practices act to degrade and dehumanize clients whose resulting conformity eases the work of nursing staff. While some nurses perceive that seclusion reduces clients' agitation, one must ask at what cost to clients' dignity, humanity, and basic human rights.

Clinical decision making involved in secluding and restraining an adult psychiatric patient: an integrative literature review

The purpose of this integrative literature review was to describe different factors involved in the decision-making process of using seclusion or restraint, and to discuss the process in practice. The data used in this review were systematically retrieved from the following databases: CINAHL, Medline and PsycINFO. Manual data retrieval was conducted from the reference lists of the papers that came up in the original database search. A total of 32 studies were selected. Results suggest that the situations that lead to the use of seclusion or restraint are always dynamic and circumstantial. During the decision-making process staff observe a patient's behaviour, assesses risk and chooses and uses interventions that aim to de-escalate the situation. This process is affected by the previous experiences and history of staff as well as the behaviour and previous experience of the patient.

Gender differences in coerced patients with schizophrenia

BACKGROUND

Despite the recent increase of research interest in involuntary treatment and the use of coercive measures, gender differences among coerced schizophrenia patients still remain understudied. It is well recognized that there are gender differences both in biological correlates and clinical presentations in schizophrenia, which is one of the most common diagnoses among patients who are treated against their will. The extent to which these differences may result in a difference in the use of coercive measures for men and women during the acute phase of the disease has not been studied.

METHODS

291 male and 231 female coerced patients with schizophrenia were included in this study, which utilized data gathered by the EUNOMIA project (European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice) and was carried out as a multi-centre prospective cohort study at 13 centers in 12 European countries. Sociodemographic and clinical characteristics, social functioning and aggressive behavior in patients who received any form of coercive measure (seclusion and/or forced medication and/or physical restraint) during their hospital stay were assessed.

RESULTS

When compared to the non-coerced inpatient population, there was no difference in sociodemographic or clinical characteristics across either gender. However coerced female patients did show a worse social functioning than their coerced male counterparts, a finding which contrasts with the non-coerced inpatient population. Moreover, patterns of aggressive behavior were different between men and women, such that women exhibited aggressive behavior more frequently, but men committed severe aggressive acts more frequently. Staff used forced medication in women more frequently and physical restraint and seclusion more frequently with men.

CONCLUSIONS

Results of this study point towards a higher threshold of aggressive behavior the treatment of women with coercive measures. This may be because less serious aggressive actions trigger the application of coercive measures in men. Moreover coerced women showed diminished social functioning, and more importantly more severe symptoms from the "excitement/hostile" cluster in contrast to coerced men. National and international recommendation on coercive treatment practices should include appropriate consideration of the evidence of gender differences in clinical presentation and aggressive behaviors found in inpatient populations.

Coercion in a locked psychiatric ward: Perspectives of patients and staff

BACKGROUND

In spite of a national strategy for reducing coercion in the mental health services, Norway still has a high rate of involuntary treatment compared to other European countries. It is therefore crucial to study various parties involved in involuntary treatment in order to reduce coercion.

RESEARCH QUESTION

How do patients and staff in a Norwegian locked psychiatric ward experience coercion?

RESEARCH DESIGN

Participant observation and interviews.

PARTICIPANTS

A total of 12 patients and 22 employees participated in this study.

ETHICAL CONSIDERATIONS

This study is accepted by the National Committee for Medical Health Research Ethics.

FINDINGS

The participants experienced coercion in different ways. Patients often felt inferior, while many of the staff felt guilty for violating patients' dignity, although they ascribed responsibility for their actions to the "system." The main themes are (1) corrections and house rules, (2) coercion is perceived as necessary, (3) the significance of material surroundings, and (4) being treated as a human being.

DISCUSSION

The discussion draws upon the concepts of vulnerability, guilty conscience, and ethical sensitivity, related to the staffs' divergent views on coercion.

CONCLUSION

Especially among staff, there are divergent views of coercion. Professionals being physically and emotionally close to the patient are more likely to understand him or her as a unique person with individual needs. If patients are kept at a distance, professionals as a group change to understand patients as members of a group with common needs and common restrictions.

Retrospective review of trends in assaults and seclusion at an acute psychiatric ward over a 5-year period

In developing countries such as South Africa, not much is known about the prevalence of assaults and seclusion occurring in mental health wards over time. Here, we describe a 5-year trend in assaults and seclusions, stratified by gender, at Stikland Hospital, South Africa. A retrospective review of clinical records of patients admitted to the acute psychiatric admission wards at Stikland and involved in assault and secluded was undertaken between 1 January 2005 and 31 December 2010. Data on the number of patient and staff assaults as well as seclusions, gender, age, marital status, level of education, level of income, duration of hospital admission and primary psychiatric diagnosis were collected. Significantly (P < 0.01) more men than women engaged in patient assaults, while significantly (P < 0.01) more men were secluded than women. On a monthly basis, the number of gender-stratified patient assaults and seclusions significantly increased (P < 0.01) throughout the study period. In conclusion, we show here that gender had a significant effect on both patient assault and seclusion numbers, which increased towards the end of the study period. Monitoring of these events is therefore important to continuously improve quality of care.

Preventing seclusion in psychiatry: a care ethics perspective on the first five minutes at admission

In this article, an intervention aimed at improving quality of care to prevent seclusion in psychiatry by focusing on the first five minutes at admission is analyzed from a care ethics perspective. Two cases are presented from an evaluation study in a psychiatric hospital. In both cases, the nurses follow the intervention protocol, but the outcome is different. In the first case, the patient ends up in the seclusion room. In the second case, this does not happen. Analyzing the cases from a care ethics perspective, we conclude that applying the intervention in the right way implies more than following the steps laid down in the protocol. It requires a new way of thinking and acting, resulting in new relationships between nurses and patients. Care ethics theory can help clarify what good care is actually about and keep in mind what is needed to apply the intervention. Thus, care ethics theory can be highly practical and helpful in changing and improving healthcare practice.

Profiles of patients admitted to a psychiatric intensive care unit: secluded with or without restraint

OBJECTIVE

To identify and describe the profiles of patients admitted to a psychiatric intensive care unit (PICU) as they relate to seclusion and restraint.

METHOD

Multiple correspondence analysis (MCA) and cluster analysis were performed with data for 114 patients admitted to a PICU from June 8, 2010, to June 7, 2011.

RESULTS

The MCA revealed that the presence or absence of seclusion and restraint was the main factor explaining the variance. Admitted patients fall into 5 profiles, 2 of which are significantly associated with seclusion and restraint: young psychotic men and women with bipolar disorder.

CONCLUSIONS

The differentiation of patient profiles as they relate to seclusion and restraint should lead to the development of profile-specific interventions before, during, and after seclusion and restraint.

Influence of patient characteristics on duration of seclusion/restrain in acute psychiatric settings in Japan

AIM

The aim of this study was to investigate the current state of duration of seclusion/restraint in acute psychiatric settings in Japan and the effect of patient characteristics on duration of seclusion/restraint.

METHODS

During an 8-month period starting from November 2008, duration of seclusion/restraint and patient characteristics were investigated in 694 psychiatric inpatients who experienced seclusion/restraint in three emergency and three acute wards at four psychiatric hospitals. Reasons for starting seclusion/restraint were also assessed. Analysis was performed using generalized linear models, with the duration of seclusion/restraint as the dependent variable and patient characteristics and reasons for starting seclusion/restraint as independent variables.

RESULTS

Of the patients secluded/restrained, 58.6% had a primary diagnosis of schizophrenia (F20-F29) and a large proportion (37.9%) were secluded/restrained due to hurting others. Median hours ofseclusion/restraint were 204 and 82 h, respectively. The duration of seclusion was longer for patients with F20-F29 than those with disorders due to psychoactive substance use (F10-F19) or other diagnoses (F40-F99), and when the reason was danger of hurting others. In contrast, the duration of restraint in female patients and in patients with F10-F19 diagnosis was shorter.

CONCLUSION

The duration of seclusion/restraint at acute psychiatric care wards in Japan are much longer than those reported by previous overseas studies. Although Japanese structure issues such as more patients per ward and a lower ratio of nurses need to be considered, skills for dealing with patients with primary diagnosis of F20-F29 secluded due to danger posed to others should be improved.

Restraint and seclusion: the perspective of service users and staff members

BACKGROUND

Restrictive measures may have important physical and psychological consequences on all persons involved. The current study examined how these are perceived by persons with intellectual disabilities and staff.

MATERIALS AND METHODS

Interviews were conducted with eight persons with intellectual disabilities who experienced a restrictive measure and their care providers. They were queried on their understanding of the restrictive measure, its impact on the relationship, their emotions and alternative interventions.

RESULTS

Restrictive measures were experienced negatively by persons with intellectual disabilities and their care providers. Service users reported feeling sad and angry, whereas staff mentioned feeling anxious. Moreover, persons with intellectual disabilities appeared to understand the goal of restrictive measures (e.g. ensuring their own and others' safety) and identified alternative interventions (e.g. speaking with a staff member or taking a walk).

CONCLUSION

This study sheds further light on how persons with intellectual disabilities and staff experience the application of restrictive measures. Debriefing sessions with service users and staff may help minimize negative consequences.

Professionals' attitudes after a seclusion reduction program: anything changed?

Changing professionals' attitudes toward seclusion is seen as an important condition to reduce its use. The purpose of this study was to determine whether professionals from a mental health institute in the Netherlands changed in their attitudes toward seclusion after implementation of a multifaceted seclusion reduction program. Professionals working on four acute admission wards filled in the Professional Attitudes Toward Seclusion Questionnaire (PATS-Q) before and after a seclusion reduction program. Changes were analyzed by comparing mean scores on the PATS-Q. After the program, professionals scored significantly higher on 'ethics' and 'more care'. As expected, no change occurred on 'reasons' for the use of seclusion. In addition, no significant changes were found on 'confidence', 'better care' and 'other care'. Significant changes in professional attitudes concerning the ethics of using seclusion and involving issues of more care were observed after a seclusion reduction program. Mental health professionals moved in the direction of 'transformers', indicating an increased criticism of the practice of seclusion and increased willingness to change their own use of seclusion.

Respect in mental health: reconciling the rhetorical hyperbole with the practical reality

Although there is a high degree of consensus in the existing literature regarding the importance of respect in mental health care, a realistic appraisal suggests that there is something of a disconnect between what is espoused in policy documents and what actually occurs in practice. As a result, this article seeks to explore and advance our understanding of the phenomenon of respect in mental health care and draws on real practice situations to illustrate this schism. To this end, the authors present three case studies that focus on the following: "use of seclusion," "respecting professional boundaries," and "horizontal workplace violence." The authors advance the, perhaps for some, provocative argument that it is relatively easy to write/speak about respect, while the reality of communicating respect to others is more difficult, challenging, and makes significant demands on the individual psychiatric/mental health nurse.

The effects of a nationwide program to reduce seclusion in the Netherlands

BACKGROUND

From 2006 to 2009, the Dutch government provided €5 m annually for a nationwide program to reduce seclusion in psychiatric hospitals by 10% a year. We aimed to establish whether the numbers of both seclusion and involuntary medication changed significantly after the start of this national program.

METHODS

Using Poisson regression to estimate difference in logit slopes, we analyzed data for 1998-2009 from the Dutch Health Care Inspectorate, retrospectively examining the national numbers of seclusion and involuntary medication before and after the start of the program.

RESULTS

The difference in slopes of the numbers of seclusion before and after the start of the program was statistically significant (difference 5.2%: p < 0.001). After the start of the program seclusions dropped 2.0% per year. Corrected for the increasing number of involuntary hospitalizations this figure was 4.7% per year. The difference in slopes of the numbers of involuntary medication did not change statistically significant (difference 0.5%, n.s.). After correction for the increasing number of involuntary hospitalizations the difference turned significant (difference 3.3%, p = 0.002).

CONCLUSIONS

After the start of the nationwide program the number of seclusions fell, and although significantly changing, the reduction was modest and failed to meet the objective of a 10% annual decrease. The number of involuntary medications did not change; instead, after correction for the number of involuntary hospitalizations, it increased.

The association for behavior analysis international position statement on restraint and seclusion

A task force authorized by the Executive Council of the Association for Behavior Analysis International (ABAI) generated the statement below concerning the techniques called restraint and seclusion. Members of the task force independently reviewed the scientific literature concerning restraint and seclusion and agreed unanimously to the content of the statement. The Executive Council accepted the statement, and it was subsequently approved by a two-thirds majority vote of the general membership. It now constitutes official ABAI policy. The position statement is posted on the ABAI Web site (www.abainternational.org/ABA/statements/RestraintSeclusion.asp). The purpose of the position statement is to provide guidance to behavior analysts and other professionals interested in the position of ABAI on these controversial topics. In extreme cases, abuses of procedures erroneously used in the name of behavior analysis are not defensible. On the other hand, behavior analysts acting ethically and in good faith are provided with guidelines for sound and acceptably safe practice. To the extent that behavior-analytic positions influence public policy and law, this statement can be presented to officials and lawmakers to guide informed decision making. At the conclusion of the document, a bibliography is provided of articles and presentations considered by one or more task force members in developing the position statement.

Evaluation of behavioral changes and subjective distress after exposure to coercive inpatient interventions

BACKGROUND

There is a lack of evidence to underpin decisions on what constitutes the most effective and least restrictive form of coercive intervention when responding to violent behavior. Therefore we compared ratings of effectiveness and subjective distress by 125 inpatients across four types of coercive interventions.

METHODS

Effectiveness was assessed through ratings of patient behavior immediately after exposure to a coercive measure and 24 h later. Subjective distress was examined using the Coercion Experience Scale at debriefing. Regression analyses were performed to compare these outcome variables across the four types of coercive interventions.

RESULTS

Using univariate statistics, no significant differences in effectiveness and subjective distress were found between the groups, except that patients who were involuntarily medicated experienced significant less isolation during the measure than patients who underwent combined measures. However, when controlling for the effect of demographic and clinical characteristics, significant differences on subjective distress between the groups emerged: involuntary medication was experienced as the least distressing overall and least humiliating, caused less physical adverse effects and less sense of isolation. Combined coercive interventions, regardless of the type, caused significantly more physical adverse effects and feelings of isolation than individual interventions.

CONCLUSIONS

In the absence of information on individual patient preferences, involuntary medication may be more justified than seclusion and mechanical restraint as a coercive intervention. Use of multiple interventions requires significant justification given their association with significant distress.

Patients' preference and experiences of forced medication and seclusion

This study examined patients' preferences for coercive methods and the extent to which patients' choices were determined by previous experience, demographic, clinical and intervention-setting variables. Before discharge from closed psychiatric units, 161 adult patients completed a questionnaire. The association between patients' preferences and the underlying variables was analyzed using logistic regression. We found that patients' preferences were mainly defined by earlier experiences: patients without coercive experiences or who had had experienced seclusion and forced medication, favoured forced medication. Those who had been secluded preferred seclusion in future emergencies, but only if they approved its duration. This suggests that seclusion, if it does not last too long, does not have to be abandoned from psychiatric practices. In an emergency, however, most patients prefer to be medicated. Our findings show that patients' preferences cannot guide the establishment of international uniform methods for managing violent behaviour. Therefore patients' individual choices should be considered.

The nature and extent of the use of physical restraint and seclusion in psychiatric practice: Report of a survey

Restraint and seclusion has been used to manage patients despite all controversies. Our study analyzed the opinions of different psychiatrists on the use of this method in their clinical practice. Most of them (80%) practice restraints as a treatment modality and believe that they are integral to the management of psychiatric patients. None is using seclusion.