Reducing coercion in mental healthcare

Effects of temporary psychiatric holds on length of stay and readmission risk among persons admitted for psychotic disorders

The practice of involuntary psychiatric commitment is central to the acute treatment of persons with severe mental illness and others in psychiatric crisis. Deciding whether a patient should be admitted involuntarily requires weighing respect for autonomy against beneficence, considering the clinical needs of the patient, and navigating ambiguous legal standards. The relative dearth of information about the impact of involuntary commitment on objective patient outcomes complicates matters ethically, legally, and clinically. To address this gap in the literature, we sought to determine the association between temporary psychiatric holds and length of stay and readmission rates among a retrospective sample of adult patients admitted to a large psychiatric hospital with diagnoses of schizophrenia, schizoaffective disorder, mania, and other psychotic disorders. In total, we identified 460 patients and 559 unique encounters meeting our inclusion criteria; 90 of the encounters were voluntary (involving a temporary psychiatric hold) and 469 were involuntary. Univariable and multivariable analyses suggested that temporary psychiatric holds were not significantly associated with either length of stay or readmission rate. These findings are relevant to clinicians who must decide whether to admit a patient involuntarily, as they suggest that making a patient involuntary is not associated with differences in length of stay or readmission risk.

Factors associated with involuntary psychiatric hospitalization in Portugal

Background

Identifying which factors contribute to involuntary psychiatric hospitalization may support initiatives to reduce its frequency. This study examines the sociodemographic, clinical, and contextual factors associated with involuntary hospitalization of patients from five Portuguese psychiatric departments in 2002, 2007 and 2012.

Methods

Data from all admissions were extracted from clinical files. A Poisson generalized linear model estimated the association between the number of involuntary hospitalizations per patient in one year and sociodemographic, clinical, and contextual factors.

Results

An increment of involuntary hospitalizations was associated with male gender [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.31; 95%CI 1.06–1.62, p < 0.05], having secondary and higher education [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.45; 95%CI 1.05–2.01, p < 0.05, and exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.89; 95%CI 1.38–2.60, p < 0.001, respectively], a psychiatric diagnosis of psychosis [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 2.02; 95%CI 1.59–2.59, p < 0.001], and being admitted in 2007 and in 2012 [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.61; 95%CI 1.21–2.16, p < 0.01, and exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 1.73; 95%CI 1.31–2.32, p < 0.001, respectively]. A decrease in involuntary hospitalizations was associated with being married/cohabitating [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.74; 95%CI 0.56–0.99, p < 0.05], having experienced a suicide attempt [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.26; 95%CI 0.15–0.42, p < 0.001], and belonging to the catchment area of three of the psychiatric services evaluated [exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.65; 95%CI 0.49–0.86, p < 0.01, exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.67; 95%CI 0.49–0.90, p < 0.01, and exp(\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\widehat{\upbeta }$$\end{document}β^) = 0.67; 95%CI 0.46–0.96, p < 0.05 for Hospital de Magalhães Lemos, Centro Hospitalar Psiquiátrico de Lisboa and Unidade Local de Saúde do Baixo Alentejo, respectively].

Conclusions

The findings suggest that involuntary psychiatric hospitalizations in Portugal are associated with several sociodemographic, clinical, and contextual factors. This information may help identify high-risk patients and inform the development of better-targeted preventive interventions to reduce these hospitalizations.

Coping with Criticism and Embracing Change—Further Reflexions on the Debate on a Mental Health Care System without Coercion

In August 2019, a manuscript was published in this journal that aimed at imagining a mental health care system that renounces the judicial control to better focus on the will and preferences of those who require support. Alternative scenarios for dealing with risk, inpatient care, and police custody were presented that elicited strong and emotionally laden reactions. This article adds further reflections to this debate, aiming at contributing explanations for this unsettlement. A productive notion of criticism is discussed, and ways to achieve change toward a more human rights-oriented psychiatric practice are outlined.

[Mental health and human rights: The experience of professionals in training with the use of mechanical restraints in Madrid, Spain]

Mechanical restraint is a coercive procedure in psychiatry, which despite being permitted in Spain, raises significant ethical conflicts. Several studies argue that non-clinical factors - such as professionals' experiences and contextual influences - may play a more important role than clinical factors (diagnosis or symptoms) in determining how these measures are employed. The aim of this study is to understand how the experiences of mental health professionals in training relate to the use of mechanical restraints in Madrid's mental health network. Qualitative phenomenological research was conducted through focus groups in 2017. Interviews were transcribed for discussion and thematic analysis with Atlas.ti. Descriptive results suggest that these measures generate emotional distress and conflict with their role as caregivers. Our findings shed light on different factors related to their experiences and contexts that are important in understanding the use of mechanical restraint, as well as the contradictions of care in clinical practice.

Digital Technologies and Coercion in Psychiatry

Psychiatry has a contentious history of coercion in the care of patients with mental illness, and legal frameworks often govern use of coercive interventions, such as involuntary hospitalization, physical restraints, and medication over objection. Research also suggests that informal coercion, including subtle inducements, leverage, or threats, is prevalent and influential in psychiatric settings. Digital technologies bring promise for expanding access to psychiatric care and improving delivery of these services; however, use and misuse of digital technologies, such as electronic medical record flags, surveillance cameras, videoconferencing, and risk assessment tools, could lead to unexpected coercion of patients with mental illness. Using several composite case examples, the author proposes that the integration of digital technologies into psychiatric care can influence patients' experiences of coercion and provides recommendations for studying and addressing these effects.

Thirty Years of Human Rights Study in the Web of Science Database (1990-2020)

The study of human rights (HR) is vital in order to enhance the development of human beings, but this field of study still needs to be better depicted and understood because violations of its core principles still frequently occur worldwide. In this study, our goal was to perform a bibliometric performance and network analysis (BPNA) to investigate the strategic themes, thematic evolution structure, and trends of HR found in the Web of Science (WoS) database from 1990 to June 2020. To do this, we included 25,542 articles in the SciMAT software for bibliometric analysis. The strategic diagram produced shows 23 themes, 12 of which are motor themes, the most important of which are discussed in this article. The thematic evolution structure presented the 21 most relevant themes of the 2011-2020 period. Our findings show that HR research is directly related to health issues, such as mental health, HIV, and reproductive health. We believe that the presented results and HR panorama presented have the potential to be used as a basis on which researchers in future works may enhance their decision making related to this field of study.

Intégration des droits humains dans la pratique du personnel infirmier faisant usage de coercition en santé mentale : recension systématique des écrits et méta-ethnographie

Introduction and background&#160;: The last decade has seen a steady and rising use of coercion in mental health care, as well as an increase in the number of forms it takes. The application of these measures frequently relies on the work of nurses, but few studies have analyzed the human rights issues raised by these practices.Aim&#160;: To produce a qualitative synthesis of how human rights are integrated into the practice of nurses who use coercion in mental health care.Methodology&#160;: A systematic review of qualitative scientific literature published between 2008 and 2018 was conducted and supplemented by a meta-ethnographic analysis.Results&#160;: The analysis of the forty-six selected studies revealed four distinct themes&#160;: coercion in mental health care as a socio-legal object, issues of recognition of human rights in mental health care, role conflict experienced by nurses, and the conceptualization of coercion as a necessary evil or a critical incident.Discussion and conclusion&#160;: Further research is needed to understand the specifics of the continuum of support and control that characterizes the coercive work of psychiatric nurses.

Between No Help and Coercion: Toward Referral to Involuntary Psychiatric Admission. A Qualitative Interview Study of Stakeholders' Perspectives

Objective: Paths toward referral to involuntary psychiatric admission mainly unfold in the contexts where people live their everyday lives. Modern health services are organized such that primary health care services are often those who provide long-term follow-up for people with severe mental illness and who serve as gatekeepers to involuntary admissions at the secondary care level. However, most efforts to reduce involuntary admissions have been directed toward the secondary health care level; interventions at the primary care level are sparse. To adapt effective measures for this care level, a better understanding is needed of the contextual characteristics surrounding individuals' paths ending in referrals for involuntary admission. This study aims to explore what characterizes such paths, based on the personal experiences of multiple stakeholders. Method: One hundred and three participants from five Norwegian municipalities participated in individual interviews or focus groups. They included professionals from the primary and secondary care levels and people with lived experience of severe mental illness and/or involuntary admission and carers. Data was subject to constant comparison in inductive analysis inspired by grounded theory. Results: Four main categories emerged from the analysis: deterioration and deprivation, difficult to get help, insufficient adaptation of services provided, and when things get acute. Combined, these illustrate typical characteristics of paths toward referral for involuntary psychiatric admission. Conclusion: The results demonstrate the complexity of individuals' paths toward referral to involuntary psychiatric admission and underline the importance of comprehensive and individualized approaches to reduce involuntary admissions. Furthermore, the findings indicate a gap in current practice between the policies to reduce involuntary admissions and the provision of, access to, and adaptation of less restrictive services for adults with severe mental illness at risk of involuntary admissions. To address this gap, further research is needed on effective measures and interventions at the primary care level.

From Wish to Reality: Soteria in Regular Care-Proof of Effectiveness of the Implementation of Soteria Elements in Acute Psychiatry

Objective: This article examines the influence of the implementation of Soteria elements on coercive measures in an acute psychiatric ward after reconstruction in 2017, thereby comparing the year 2016 to the year 2019. The special feature is that this is the only acute psychiatric ward in Hennigsdorf Hospital, connected now both spatially and therapeutically to an open ward and focusing on the treatment of patients suffering from schizophrenia and schizophrenia spectrum disorders. Methods: The following parameters were examined: aggressive assaults, use of coercion (mechanical restraints), duration of treatment in open or locked ward, type of discharge, coercive medication, and dosage of applied antipsychotics. For this purpose, the data of all legally accommodated patients in the year 2016 (before the reconstruction) and 2019 (after the reconstruction) were statistically analyzed in a pre-post mirror quasi-experimental design. Results: In 2019, the criteria of the Soteria Fidelity Scale for a ward with Soteria elements were reached. In comparison to 2016 with a comparable care situation and a comparable patient clientele, there was now a significant decrease in aggressive behavior toward staff and fellow patients, a significantly reduced number of fixations, a significantly reduced overall duration of inpatient stay, and a significant increase in treatment time in the open area of our acute ward. Conclusion: The establishment of Soteria elements in the acute psychiatric ward leads to a verifiable less violent environment of care for severely ill patients and to a drastic reduction in coercive measures.

Incidences of Involuntary Psychiatric Detentions in 25 U.S. States

OBJECTIVE

Characterizing commitment as an involuntary psychiatric emergency detention that possibly extends into a longer-term detention, the authors aimed to calculate population rates of detentions and chart interstate differences since 2011 by means of publicly available state counts.

METHODS

Searches of state health and court websites yielded counts from 38 U.S. states. Usable counts from 25 states were classified as emergency or longer-term detentions and converted to crude rates per 100,000 people by using Census Bureau figures.

RESULTS

All-ages rates (per 100,000 people) of emergency detentions ranged from 29 in Connecticut to 966 in Florida. In 22 states with continuous 2012-2016 data, the average rate increased from 273 to 309. In four of five states with separate counts for adults and minors, rates over time for both were nearly parallel. In eight states that provided relevant data, the mean longer-term detention rate was 42% of a state's average emergency detention rate. Only one state provided length-of-stay data, and one counted both detentions and persons detained. In 24 states-accounting for 51.9% of the U.S. population-591,402 emergency involuntary detentions were recorded in 2014, the most recent year with most states reporting, a crude rate of 357 per 100,000.

CONCLUSIONS

Incidences of involuntary psychiatric detentions between 2011 and 2018 varied 33-fold across 25 states, and the mean state rate increased by three times the mean state population increase. Omissions in most states' counts clouded interpretation. More valid incidences obtained from standardized national data would improve analysis of the controversial yet opaque procedure of involuntary inpatient civil commitment.

The Role of Implicit and Explicit Staff Attitudes in the Use of Coercive Measures in Psychiatry

Many determinants leading to the use of different coercive measures in psychiatry have been widely studied and it seems that staff attitudes play a crucial role when it comes to the decision-making process about using coercion. However, research results about staff attitudes and their role in the use of coercive measures are inconsistent. This might be due to a focus on self-report studies asking for explicit answers, which involves the risk of bias. This study aimed to expand research on this topic by examining the impact of explicit and implicit staff attitudes on the use of coercive measures in clinical practice. In addition, the influence of gender, profession (nurses, psychiatrists), and years of professional experience as well as their influence on staff attitudes were examined. An adaption of the implicit association measure, the Go/No-Go Association Task (GNAT), with the target category coercion and distracter stimuli describing work load, as well as the explicit questionnaire Staff Attitudes to Coercion Scale (SACS) was completed by staff (N = 149) on 13 acute psychiatric units in 6 hospitals. Data on coercive measures as well as the total number of treated cases for each unit was collected. Results showed that there was no association between staff's implicit and explicit attitudes toward coercion, and neither measure was correlated with the local frequency of coercive measures. ANOVAs showed a significant difference of the GNAT result for the factor gender (F = 9.32, p = 0.003), demonstrating a higher tendency to justify coercion among female staff members (M = -0.23, SD = ±0.35) compared to their male colleagues (M = -0.41, SD = ±0.31). For the SACS, a significant difference was found for the factor profession (F = 7.58, p = 0.007), with nurses (M = 2.79, SD = ±1.40) showing a more positive attitude to the use of coercion than psychiatrists (M = 2.15, SD = ±1.11). No significant associations were found regarding the extent of professional experience. Results indicate a complex interaction between implicit and explicit decision-making processes dependent on specific contexts. We propose future research to include primers for more context-related outcomes. Furthermore, differences in gender suggest a need to direct attention toward occupational safety and possible feelings of anxiety in the workplace, especially for female staff members.

The use of mechanical restraint in Pacific Rim countries: an international epidemiological study

AIMS

The use of mechanical restraint is a challenging area for psychiatry. Although mechanical restraint remains accepted as standard practice in some regions, there are ethical, legal and medical reasons to minimise or abolish its use. These concerns have intensified following the Convention on the Rights of Persons with Disabilities. Despite national policies to reduce use, the reporting of mechanical restraint has been poor, hampering a reasonable understanding of the epidemiology of restraint. This paper aims to develop a consistent measure of mechanical restraint and compare the measure within and across countries in the Pacific Rim.

METHODS

We used the publicly available data from four Pacific Rim countries (Australia, New Zealand, Japan and the United States) to compare and contrast the reported rates of mechanical restraint. Summary measures were computed so as to enable international comparisons. Variation within each jurisdiction was also analysed.

RESULTS

International rates of mechanical restraint in 2017 varied from 0.03 (New Zealand) to 98.9 (Japan) restraint events per million population per day, a variation greater than 3000-fold. Restraint in Australia (0.17 events per million) and the United States (0.37 events per million) fell between these two extremes. Variation as measured by restraint events per 1000 bed-days was less extreme but still substantial. Within all four countries there was also significant variation in restraint across districts. Variation across time did not show a steady reduction in restraint in any country during the period for which data were available (starting from 2003 at the earliest).

CONCLUSIONS

Policies to reduce or abolish mechanical restraint do not appear to be effecting change. It is improbable that the variation in restraint within the four examined Pacific Rim countries is accountable for by psychopathology. Greater efforts at reporting, monitoring and carrying out interventions to achieve the stated aim of reducing restraint are urgently needed.

Professionals' perspectives on factors within primary mental health services that can affect pathways to involuntary psychiatric admissions

Background

Reducing involuntary psychiatric admissions has been on the international human rights and health policy agenda for years. Despite the last decades’ shift towards more services for adults with severe mental illness being provided in the community, most research on how to reduce involuntary admissions has been conducted at secondary health care level. Research from the primary health care level is largely lacking. The aim of this study was to explore mental health professionals’ experiences with factors within primary mental health services that might increase the risk of involuntary psychiatric admissions of adults, and their views on how such admissions might be avoided.

Methods

Qualitative semi-structured interviews with thirty-two mental health professionals from five Norwegian municipalities. Data were analysed according to the Systematic Text Condensation method.

Results

Within primary mental health care professionals experienced that a number of factors could increase the risk of involuntary psychiatric admissions. Insufficient time and flexibility in long-term follow-up, limited resources, none or arbitrary use of crisis plans, lack of tailored housing, few employment opportunities, little diversity in activities offered, limited opportunities for voluntary admissions, inadequate collaboration between services and lack of competence were some of the factors mentioned to increase the risk of involuntary psychiatric admissions. Several suggestions on how involuntary psychiatric admissions might be avoided were put forward.

Conclusions

Mental health professionals within primary mental health care experienced that their services might play an active part in preventing the use of involuntary psychiatric admissions, suggesting potential to facilitate a reduction by intervening at this service level. Health authorities’ incentives to reduce involuntary psychiatric admissions should to a greater extent incorporate the primary health care level. Further research is needed on effective interventions and comprehensive models adapted for this care level.

Compulsory admissions of patients with mental disorders: State of the art on ethical and legislative aspects in 40 European countries

Background.

Compulsory admission procedures of patients with mental disorders vary between countries in Europe. The Ethics Committee of the European Psychiatric Association (EPA) launched a survey on involuntary admission procedures of patients with mental disorders in 40 countries to gather information from all National Psychiatric Associations that are members of the EPA to develop recommendations for improving involuntary admission processes and promote voluntary care.

Methods.

The survey focused on legislation of involuntary admissions and key actors involved in the admission procedure as well as most common reasons for involuntary admissions.

Results.

We analyzed the survey categorical data in themes, which highlight that both medical and legal actors are involved in involuntary admission procedures.

Conclusions.

We conclude that legal reasons for compulsory admission should be reworded in order to remove stigmatization of the patient, that raising awareness about involuntary admission procedures and patient rights with both patients and family advocacy groups is paramount, that communication about procedures should be widely available in lay-language for the general population, and that training sessions and guidance should be available for legal and medical practitioners. Finally, people working in the field need to be constantly aware about the ethical challenges surrounding compulsory admissions.

A Key, Not a Straitjacket: The Case for Interim Mental Health Legislation Pending Complete Prohibition of Psychiatric Coercion in Accordance with the Convention on the Rights of Persons with Disabilities

The practice of coercion on the basis of psychosocial disability is plainly discriminatory. This has resulted in a demand from the Committee on the Rights of Persons with Disabilities (the CRPD Committee) for a paradigm shift away from the traditional biomedical model and a global ban on compulsion in the psychiatric context. However, that has not occurred. This paper considers conflicting pronouncements of the CRPD Committee and other United Nations bodies. Assuming the former's interpretations of the Convention on the Rights of Persons with Disability (CRPD) are accurate, involuntary psychiatric detention and enforced treatment on the basis of psychosocial disability are prima facie discriminatory and unlawful practices. However, dedicated mental health legislation both permits discrimination and protects and enhances rights. This paper proposes a practical way out of the present impasse: the global introduction of interim "holding" legislation lacking full compliance with the CRPD. While imperfect, such a framework would facilitate a move toward a complete ban on psychiatric coercion. The paper outlines four essential ingredients that any interim legislation ought to contain, including clear timebound targets for full CRPD implementation. It concludes by urging the CRPD Committee to take the unprecedented step of issuing a general comment providing reluctant "permission" for the progressive realization of respect for articles 12 and 14 of the CRPD.

Experiences of Individuals Who Were Physically Restrained in the Emergency Department

IMPORTANCE

Individuals with behavioral disorders are increasingly presenting to the emergency department (ED), and associated episodes of agitation can cause significant safety threats to patients and the staff caring for them. Treatment includes the use of physical restraints, which may be associated with injuries and psychological trauma; to date, little is known regarding the perceptions of the use of physical restraint among individuals who experienced it in the ED.

OBJECTIVE

To characterize how individuals experience episodes of physical restraint during their ED visits.

DESIGN, SETTING, AND PARTICIPANTS

In this qualitative study, semistructured, 1-on-1, in-depth interviews were conducted with 25 adults (ie, aged 18 years or older) with a diverse range of chief concerns and socioeconomic backgrounds who had a physical restraint order associated with an ED visit. Eligible visits included those presenting to 2 EDs in an urban Northeast city between March 2016 and February 2018. Data analysis occurred between July 2017 and June 2018.

MAIN OUTCOMES AND MEASURES

Basic participant demographic information, self-reported responses to the MacArthur Perceived Coercion Scale, and experiences of physical restraint in the ED.

RESULTS

Data saturation was reached with 25 interviews (17 [68%] men; 18 [72%] white; 19 [76%] non-Hispanic). The time between the patient's last restraint and the interview ranged from less than 2 weeks to more than 6 months. Of those interviewed, 22 (88%) reported a combination of mental illness and/or substance use as contributing to their restraint experience. Most patients (20 [80%]) said that they felt coerced to present to the ED. Three primary themes were identified from interviews, as follows: (1) harmful experiences of restraint use and care provision, (2) diverse and complex personal contexts affecting visits to the ED, and (3) challenges in resolving their restraint experiences, leading to negative consequences on well-being.

CONCLUSIONS AND RELEVANCE

In this qualitative study, participants described a desire for compassion and therapeutic engagement, even after they experienced coercion and physical restraint during their visits that created lasting negative consequences. Future work may need to consider more patient-centered approaches that minimize harm.

Nurses' perspectives on human rights when coercion is used in psychiatry: a systematic review protocol of qualitative evidence

BACKGROUND

The World Health Organization describes the perpetuation of human rights violations against people with mental health problems as a global emergency. Despite this observation, recent studies suggest that coercive measures, such as seclusion, restraints, involuntary hospitalization, or involuntary treatment, are steadily or increasingly being used without proof of their effectiveness. In nursing, several literature reviews have focused on understanding nurses' perspectives on the use of seclusion and restraints. Although many studies describe the ethical dilemmas faced by nurses in this context, to this date, their perspectives on patient's rights when a broad variety of coercive measures are used are not well understood. The aim of this review is to produce a qualitative synthesis of how human rights are actually integrated into psychiatric and mental health nursing practice in the context of coercive work.

METHODS

Noblit and Hare's meta-ethnographic approach will be used to conduct this systematic review. The search will be conducted in CINAHL, Medline, PsycINFO, ERIC, and Scopus databases, using the PICo model (Population, phenomenon of Interest, Context) and a combination of keywords and descriptors. It will be complemented by a manual search of non-indexed articles, gray literature, and other applicable data sources, such as human rights related documents. Qualitative and mixed-method study designs will be included in this review. Empirical and peer-reviewed articles published between 2008 and 2019 will be selected. Articles will be evaluated independently by two reviewers to determine their inclusion against eligibility criteria. The quality of the selected papers will then be independently evaluated by two reviewers, using the Joanna Briggs Institute's Checklist for Qualitative Research. Data extraction and content analysis will focus on first- and second-order constructs, that is, the extraction of research participants' narratives and their interpretation.

DISCUSSION

This review will provide a synthesis of how psychiatric and mental health nurses integrate human rights principles into their practice, as well as it will identify research gaps in this area. The results of this review will then provide qualitative evidence to better understand how nurses can contribute to the recognition, protection, and advocate for human rights in a psychiatric context.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42019116862.