Nurses' judgments regarding seclusion and restraint of psychiatric patients: a social judgment analysis

Variation in opinions on coercion use among mental healthcare professionals: a questionnaire study

INTRODUCTION

Even if coercive measures are widely applied in psychiatry and have numerous well-known drawbacks, there is limited known on the agreement among mental healthcare professionals' opinions on their use. In a questionnaire study using standardized scenarios, we investigated variation in staff opinions on coercion.

METHODS

In a web-based survey distributed to staff at three psychiatry hospitals, respondents were asked to consider if and what coercion to use by introducing two hypothetical scenarios involving involuntary psychiatric admission and in-hospital coercion.

RESULTS

One hundred thirty-two out of 601 invited staff members responded to the survey (Response Rate = 22%). There was large variation in participating staff members' opinions on how to best manage critical situations and what coercive measures were warranted. In the first scenario, 57% of respondents (n = 76) believed that the patient should be involuntarily admitted to hospital while the remaining respondents believed that the situation should be managed otherwise. Regarding the second scenario, 62% of respondents responded that some in-hospital coercion should be used. The majority of respondents believed that colleagues would behave similarly (60%) or with a tendency towards more coercion use (34%). Male gender, being nursing staff and having less coercion experience predicted being less inclined to choose involuntary hospital admission.

CONCLUSION

There is a high degree of variation in coercion use. This study suggests that this variation persists despite staff members being confronted with the same standardized situations. There is a need for evidence-based further guidance to minimize coercion in critical mental healthcare situations.

Influence of nursing staff attitudes and characteristics on the use of coercive measures in acute mental health services-A systematic review

WHAT IS KNOWN ON THE SUBJECT?: Aggressive behaviour is a major problem in clinical practice of mental health care and can result in the use of coercive measures. Coercive measures are dangerous for psychiatric patients and international mental healthcare works on the elimination of these interventions. There is no previous review that summarizes the attitude of nursing staff towards coercive measures and the influence of nursing staff characteristics on attitude towards and the use of coercive measures. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The attitude of nurses shifted from a therapeutic paradigm (coercive measures have positive effects on patients) to a safety paradigm (coercive measures are undesirable, but necessary for the wards' safety). Nurses express the need for less coercive interventions to prevent seclusion and restraint, but their perception of intrusiveness is influenced by how often they use specific coercive measures. The knowledge from scientific literature on the influence of nursing staff on coercive measures is highly inconclusive, although the feeling of safety of nurses might prove to be promising for further research. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There is need for increased attention specifically for the feeling of safety of nurses, to better equip nurses for their difficult work on acute mental health wards. ABSTRACT: Introduction The use of coercive measures generally has negative effects on patients. To help prevent its use, professionals need insight into what nurses believe about coercion and which staff determinants may influence its application. There is need for an integrated review on both attitude and influence of nurses on the use of coercion. Aim To summarize literature concerning attitude of nurses towards coercive measures and the influence of staff characteristics on the use of coercive measures. Method Systematic review. Results The attitude of nurses changed during the last two decades from a therapeutic to a safety paradigm. Nurses currently view coercive measures as undesirable, but necessary to deal with aggression. Nurses express the need for less intrusive interventions, although familiarity probably influences its perceived intrusiveness. Literature on the relation between staff characteristics and coercive measures is inconclusive. Discussion Nurses perceive coercive measures as unwanted but still necessary to maintain safety on psychiatric wards. Focussing on the determinants of perception of safety might be a promising direction for future research. Implications for practice Mental health care could improve the focus on the constructs of perceived safety and familiarity with alternative interventions to protect patients from unnecessary use of coercive interventions.

Psychiatric Nurses' Emotional and Ethical Experiences Regarding Seclusion and Restraint

The purpose of this study was to describe psychiatric nurses' emotional and ethical experiences regarding seclusion and restraint, and factors associated with these experiences. The data (n = 165) was collected in southern Finland, using the electronic version of the Seclusion and Restraint Experience Questionnaire (SREQ) and analyzed with statistical methods. We found that the experiences of control and duty were strongly emphasized in responses, especially among nurses with short work experience or temporary employment. These results offer new information about psychiatric nurses' experiences regarding seclusion and restraint. These results can be utilized both in the teaching and in management of the nursing.

An integrative review exploring decision-making factors influencing mental health nurses in the use of restraint

WHAT IS KNOWN ON THE SUBJECT?: There is emerging evidence highlighting the counter therapeutic impact of the use of restraint and promoting the minimization of this practice in mental health care. Mental health nurses are often the professional group using restraint and understanding factors influencing their decision-making becomes critical. To date, there are no other published papers that have undertaken a similar broad search to review this topic. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Eight emerging themes are identified as factors influencing mental health nurses decisions-making in the use of restraint. The themes are: 'safety for all', 'restraint as a necessary intervention', 'restraint as a last resort', 'role conflict', 'maintaining control', 'staff composition', 'knowledge and perception of patient behaviours', and 'psychological impact'. 'Last resort' appears to be the mantra of acceptable restraint use, although, to date, there are no studies that specifically consider what this concept actually is. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: These findings should be considered in the evaluation of the use of restraint in mental health settings and appropriate strategies placed to support shifting towards restraint minimization. As the concept of 'last resort' is mentioned in many policies and guidelines internationally with no published understanding of what this means, research should prioritize this as a critical next step in restraint minimization efforts.

INTRODUCTION

While mechanical and manual restraint as an institutional method of control within mental health settings may be perceived to seem necessary at times, there is emergent literature highlighting the potential counter-therapeutic impact of this practice for patients as well as staff. Nurses are the professional group who are most likely to use mechanical and manual restraint methods within mental health settings. In-depth insights to understand what factors influence nurses' decision-making related to restraint use are therefore warranted.

AIM

To explore what influences mental health nurses' decision-making in the use of restraint.

METHOD

An integrative review using Cooper's framework was undertaken.

RESULTS

Eight emerging themes were identified: 'safety for all', 'restraint as a necessary intervention', 'restraint as a last resort', 'role conflict', 'maintaining control', 'staff composition', 'knowledge and perception of patient behaviours', and 'psychological impact'. These themes highlight how mental health nurses' decision-making is influenced by ethical and safety responsibilities, as well as, interpersonal and staff-related factors.

CONCLUSION

Research to further understand the experience and actualization of 'last resort' in the use of restraint and to provide strategies to prevent restraint use in mental health settings are needed.

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.

The Eileen Skellern Lecture 2014: physical restraint: in defence of the indefensible?

Aggression is reported to be prevalent in psychiatric inpatient care and its frequency towards healthcare professionals is well documented. While aggression may not be entirely avoidable, its incidence can be reduced through prevention and the minimization of restrictive practices such as physical restraint. The study aims to explore three common 'defences' to account for the use of physical restraint; to challenge each defence with regard to the evidence base; and to identify how services are responding to the challenge of reducing the use of restrictive interventions. Following a number of investigations to highlight serious problems with the use of physical restraint, it seems timely to examine its efficacy in light of the evidence base. In order to do this, three key defences for its use will be challenged using the literature. A combination of interventions to minimize the use of restraint including advance planning tools, and recognition of potential trauma is necessary at an organizational and individual level. Patients can be severely traumatized by the use of restrictive practices and there is a drive to examine, and reduce the use and impact of using these models that incorporate trauma informed care (TIC) and person centredness.

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.

Factor analysis of the French version of the shorter 12-item Perception of Aggression Scale (POAS) and of a new modified version of the Overt Aggression Scale (MOAS)

Psychiatric staff perceptions of aggression by psychiatric patients may affect the therapeutic relationship between care providers and patients in institutions. Attitudes to and the subjective experience of violence may also differ substantially between members of a single care team. This study seeks to validate the French versions of scales of staff attitudes to and subjective experience of institutional violence: a new, modified version of the Overt Aggression Scale (MOAS) to measure the subjective perception of the frequency of aggression in the ward; and the Perception of Aggression Scale (POAS) to assess attitudes to the expression of violence by psychiatric patients. Frontline staff (n = 362) from eight French-language psychiatric institutions in the province of Quebec were surveyed. Factor analyses were performed to determine the validity of the French-language MOAS and POAS. As expected, a four-factor structure emerged for the MOAS. For the 12-item POAS, a three-factor structure was found: (1) 'Aggression as a dysfunctional/undesirable phenomenon'; (2) 'Aggression as a positive expression'; and (3) 'Aggression as a protective measure'. This study supports use of the French MOAS and POAS in assessing staff attitudes to and subjective experience of aggression in future projects to explore the perception and management of inpatient violence.

How nurse practitioners make decisions regarding coronary heart disease risk: a social judgment analysis

PURPOSE

Understanding how nurse practitioners use clinical decision skills in practice has the potential to guide education programs to ensure safe, competent, and high quality advanced nursing practice. This study used the lens of social judgment theory to examine the clinical decision making of 60 nurse practitioners.

METHODS

A three-group pretest-posttest comparison design was used to evaluate how much insight nurse practitioners had into their clinical decision-making process.

FINDINGS

Nurse practitioners had modest insight into their clinical decision-making process.

CONCLUSION

Self-insight has implications for enhancing nurses' decision making, improving education, and fostering agreement among advanced practice nurses.

IMPLICATIONS FOR NURSING PRACTICE

Self-insight has implications for developing professional decision making and promoting appropriate educational opportunities for advanced practice nurses.

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

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

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

METHODS

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

CONCLUSIONS

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

Psychiatric nurses' decision to restrain

The use of restraints in all health care settings has come under increased scrutiny in recent years. Although the organizational context has been suggested as a possible influence on restraint use, few researchers have examined whether organizational factors affect use of restraints and nurses' decisions to restrain patients hospitalized in psychiatric facilities. The purpose of this study was to examine the association of nurses' work empowerment (an indicator of organizational culture) with nurses' decision to restrain. This study also examined the association between individual characteristics of the patient and of the nurses with nurses' decision to restrain. Lastly, this study examined the decision patterns used by psychiatric nurses in response to patient situations in which restraint might be considered.

Occupational therapists’ decision-making in the management of clients with upper limb hypertonicity

This study applied social judgement theory to the exploration of factors influencing occupational therapists' decision-making when they manage upper limb hypertonicity in clients with cerebral palsy. To achieve this goal, both objective and stated policies were investigated. This quantitative study drew information from a literature review and a survey with experienced occupational therapists to identify 12 factors that could influence decision-making. Based on these 12 factors 110 case vignettes of individuals with cerebral palsy and upper limb hypertonicity were generated. Intervention decisions were elicited from 18 experienced occupational therapists for each of the 110 case vignettes. Therapists were also asked to rank the factors in order of perceived importance. Occupational therapists generally used severity of spasticity, wrist and finger posture, and client and family background information to guide their clinical intervention choices. However, therapists demonstrated poor insight into the nature of their decision-making processes. This was highlighted in the disparity between their stated and objective policies. These findings have implications for both the professional development of therapists and the training of students.

A practitioner's guide to persuasion: an overview of 15 selected persuasion theories, models and frameworks

OBJECTIVE

To provide a brief overview of 15 selected persuasion theories and models, and to present examples of their use in health communication research.

RESULTS

The theories are categorized as message effects models, attitude-behavior approaches, cognitive processing theories and models, consistency theories, inoculation theory, and functional approaches.

CONCLUSIONS

As it is often the intent of a practitioner to shape, reinforce, or change a patient's behavior, familiarity with theories of persuasion may lead to the development of novel communication approaches with existing patients.

PRACTICE IMPLICATIONS

This article serves as an introductory primer to theories of persuasion with applications to health communication research. Understanding key constructs and general formulations of persuasive theories may allow practitioners to employ useful theoretical frameworks when interacting with patients.

To Provide or Not to Provide Treatment? That is the Question

It is generally accepted that whether or not a client receives occupational therapy should be based on the client's needs not on the therapist that the client sees. However, in the United Kingdom there is little evidence to show that treatment provision is similar between therapists or even that therapists share a common rationale for providing treatment. This research investigated paediatric occupational therapists' beliefs about and intentions to provide treatment for children with coordination difficulties.

Ten paediatric occupational therapists were recruited from two National Health Service Scotland Health Boards. The data were collected at one time point. Intentions and beliefs about treatment provision were explored and measured both at general and at case (situation-specific) levels. Quantitative and qualitative data were collected concurrently. Statistical and thematic approaches to analysis were applied.

The findings showed that the therapists shared similar general intentions and beliefs about providing treatment. However, the situation-specific intentions to provide treatment varied considerably between the therapists. The situation-specific intentions were characterised by consideration of the client's individual circumstances and a variation in the interpretations made about the information available. The beliefs that possibly contributed to the variation in the situation-specific intentions were also identified. This research informs the occupational therapy profession about issues related to the expectation that treatment provision is similar between therapists.

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

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

The use of cognitive continuum theory and patient scenarios to explore nurse prescribers’ pharmacological knowledge and decision-making

BACKGROUND

Nurses have been involved in prescribing in England since 1996, and to date over 41,000 nurses are registered with the Nursing and Midwifery Council as prescribers. The majority of evaluative research on nurse prescribing is descriptive and relies on self-report and assessment of patient satisfaction.

OBJECTIVES

To explore and test nurse prescribers' pharmacological knowledge and decision-making.

DESIGN

An exploratory approach to test the usefulness of patient scenarios in addressing the reasons why nurses decide whether or not to prescribe was utilised. Semi-structured interviews with nurse prescribers using patient scenarios were used as proxy methods of assessment of how nurses made their prescribing decisions.

SETTING

Two primary care trusts in the southeast of England were the settings for this study.

PARTICIPANTS

Purposive sampling to ensure there was a mixed group of prescribers was used to enable detailed exploration of the research objectives and to obtain in-depth understanding of the complex activities involved in nurse prescribing.

METHODS

Interviews and case scenarios. The use of cognitive continuum theory guided the analysis.

RESULTS

The majority of participants were unable to identify the issues involved in all the scenarios; they also failed to provide an acceptable solution to the problem, suggesting that they would refer the patient to the general practitioner. A similar number described themselves as 'very confident' while seven participants felt that they were 'not confident' in dealing with medication issues, four of whom were practising prescribing.

CONCLUSIONS

The effects of social and institutional factors are important in the decision-making process. The lack of appropriate pharmacological knowledge coupled with lack of confidence in prescribing was demonstrated. The scenarios used in this study indicate that nurses are perhaps knowledgeable in their small area of practise but flounder outside this. Further research could be conducted with a larger sample and with more scenarios to explore the decision-making and the pharmacological knowledge base of nurse prescribers, particularly in the light of government policy to extend prescribing rights to non-medical prescribers, including pharmacists.

Nurses' critical event risk assessments: a judgement analysis

AIMS

To explore and explain nurses' use of readily available clinical information when deciding whether a patient is at risk of a critical event.

BACKGROUND

Half of inpatients who suffer a cardiac arrest have documented but unacted upon clinical signs of deterioration in the 24 hours prior to the event. Nurses appear to be both misinterpreting and mismanaging the nursing-knowledge 'basics' such as heart rate, respiratory rate and oxygenation. Whilst many medical interventions originate from nurses, up to 26% of nurses' responses to abnormal signs result in delays of between one and three hours.

METHODS

A double system judgement analysis using Brunswik's lens model of cognition was undertaken with 245 Dutch, UK, Canadian and Australian acute care nurses. Nurses were asked to judge the likelihood of a critical event, 'at-risk' status, and whether they would intervene in response to 50 computer-presented clinical scenarios in which data on heart rate, systolic blood pressure, urine output, oxygen saturation, conscious level and oxygenation support were varied. Nurses were also presented with a protocol recommendation and also placed under time pressure for some of the scenarios. The ecological criterion was the predicted level of risk from the Modified Early Warning Score assessments of 232 UK acute care inpatients.

RESULTS

Despite receiving identical information, nurses varied considerably in their risk assessments. The differences can be partly explained by variability in weightings given to information. Time and protocol recommendations were given more weighting than clinical information for key dichotomous choices such as classifying a patient as 'at risk' and deciding to intervene. Nurses' weighting of cues did not mirror the same information's contribution to risk in real patients. Nurses synthesized information in non-linear ways that contributed little to decisional accuracy. The low-moderate achievement (R(a)) statistics suggests that nurses' assessments of risk were largely inaccurate; these assessments were applied consistently among 'patients' (scenarios). Critical care experience was statistically associated with estimates of risk, but not with the decision to intervene.

CONCLUSION

Nurses overestimated the risk and the need to intervene in simulated paper patients at risk of a critical event. This average response masked considerable variation in risk predictions, the need for action and the weighting afforded to the information they had available to them. Nurses did not make use of the linear reasoning required for accurate risk predictions in this task. They also failed to employ any unique knowledge that could be shown to make them more accurate. The influence of time pressure and protocol recommendations depended on the kind of judgement faced suggesting then that knowing more about the types of decisions nurses face may influence information use.

RELEVANCE TO CLINICAL PRACTICE

Practice developers and educators need to pay attention to the quality of nurses' clinical experience as well as the quantity when developing judgement expertise in nurses. Intuitive unaided decision making in the assessment of risk may not be as accurate as supported decision making. Practice developers and educators should consider teaching nurses normative rules for revising probabilities (even subjective ones) such as Bayes' rule for diagnostic or assessment judgements and also that linear ways of thinking, in which decision support may help, may be useful for many choices that nurses face. Nursing needs to separate the rhetoric of 'holism' and 'expertise' from the science of predictive validity, accuracy and competence in judgement and decision making.

Understanding how nurse practitioners estimate patients' risk for coronary heart disease: a judgment analysis

AIM

This paper is a report of a study to examine how nurse practitioners combine information when estimating patient risk of coronary heart disease.

BACKGROUND

In the United States of America and other countries, nurse practitioners are increasingly working alongside physicians in primary healthcare settings. Given this role, nurse practitioners represent an important resource in early detection of numerous diseases. Understanding how nurse practitioners use patient characteristics (cues) to form estimates of patient risk for disease may improve general disease prevention efforts.

METHOD

Social judgment theory and its lens model analysis are concerned with the correspondence between a person's judgments and the environment. This approach was applied to examine how 15 nurse practitioners weighted eight risk factors for coronary heart disease, how accurate practitioners were in assessing patient risk for coronary heart disease, and how much self-insight practitioners had into their own risk estimation processes. The data were collected in 2006.

RESULTS

Nurse practitioners showed moderate to high accuracy and evinced a variety of cue-weighting strategies. Insight into their own judgment policies was modest. The lens model analysis revealed that most practitioners had lower values on knowledge of the ecology than they did on cognitive control.

CONCLUSION

Educational efforts aimed at improving detection of patients at risk for diseases might do better to target increasing clinicians' understanding of cue-criteria relationships, than to stress themes of consistency in evaluating patients.

International variation in containment measures for disturbed psychiatric inpatients: A comparative questionnaire survey

BACKGROUND

Disturbed psychiatric inpatients are managed using a range of containment measures (e.g. seclusion, mechanical restraint) whose use differs by country. Little is known about why these differences exist, or about how staff choose between the different methods available to them.

AIMS

To compare psychiatric professionals attitudes to containment measures between countries with different practices, and to discover what factors have the greatest impact on preparedness to use a containment method.

METHOD

Surveys of psychiatric professionals in the United Kingdom, the Netherlands, Finland, and Australia, using the Attitude to Containment Measures Questionnaire.

RESULTS

Relative approval of different containment measures broadly matched what we know about different practices, with some notable differences. Staff in Finland expressed the highest level of approval of containment, staff in the UK the least, with those in the Netherlands in between. Individuals' preferences for different containment measures were largely determined by whether they considered it (i) safe for the patients undergoing it, (ii) prevented them from injuring others, and (iii) quickly calmed them.

CONCLUSION

Future evaluation research on containment measures should use time taken to calm the patient, injury to patients and others, as primary outcomes. National clinical audit and injury reporting systems would also enable the identification of methods that are truly physically injurious to patients, aiding in the rational selection of appropriate containment measures.

Evidence base for practice: reduction of restraint and seclusion use during child and adolescent psychiatric inpatient treatment

BACKGROUND

Restraint and seclusion of children has great potential for harm. Since the mid-1980s, psychiatric inpatient personnel for children and adolescents have put considerable energy in reducing the use of extreme measures of aggression management. While the use of restraints is a particular problem in the United States, aggression management and means of control in psychiatric settings is an international issue.

APPROACH

The core question of this review was: What is the current state of the evidence supporting restraint reduction efforts with children and adolescents? Studies were reviewed and critiqued that related to programs of restraint reduction, restraint reduction methods, and aggression management. Internationally, there seems to be more emphasis on reducing coercive measures by understanding the context of their use. Thus, studies exploring staff perceptions and decisions concerning coercive measures were also examined.

FINDINGS

The evidence supporting restraint reduction methods in the United States comes mainly from case study reports of clinical sites' quality improvement projects. Consequently, a collection of studies is accumulating that supports a multi-strategy approach to restraint reduction. Limited evidence exists for aggression management measures and training in de-escalation techniques. Controversial aggression management techniques such as the use of pro re nata medication and holding continue to be used with very little support for their efficacy.

RECOMMENDATIONS

Recommendations include taking a view of restraint and seclusion as emergency measures to address dangerous aggression, not interventions examined in controlled studies. As such it is suggested that sites pool data on restraint use and reduction efforts to create a database for benchmarking and studying variations among hospitals. Furthermore, attention should also be given to developing additional means for addressing aggressive behaviors.

On conflict, containment and the relationship between them

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

A Systematic Review of the Safety and Effectiveness of Restraint and Seclusion as Interventions for the Short-Term Management of Violence in Adult Psychiatric Inpatient Settings and Emergency Departments

AIMS

The aim of this review was to assess whether restraint and seclusion are safe and effective interventions for the short-term management of disturbed/violent behaviour. Staff and service user perspectives on the use of these interventions were also considered. The review was undertaken as part of the development process for a national guideline on the short-term management of disturbed/violent behaviour in adult psychiatric inpatient settings and emergency departments in the United Kingdom.

METHOD

An exhaustive literature search was undertaken. Systematic reviews, before and after studies, as well as qualitative studies were included. Searches were run from 1985 to 2002.

FINDINGS

Thirty-six eligible studies were identified. However, none were randomised controlled trials. Most of the included studies had many limitations, such as small sample sizes, confounders not adequately accounted for, potential selection bias, poorly reported results, and lack of clarity as to whether mechanical restraints were used. This review must therefore be viewed as a mapping exercise, which illustrates the range and quality of studies that have been undertaken in this area to date.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Insufficient evidence is available to determine whether seclusion and restraint are safe and/or effective interventions for the short-term management of disturbed/violent behaviour in adult psychiatric inpatient settings. These interventions should therefore be used with caution and only as a last resort once other methods of calming a situation and/or service user have failed.

Clinical Judgments About Endotracheal Suctioning: What Cues Do Expert Pediatric Critical Care Nurses Consider?

Making accurate and timely judgments based on multiple ways of knowing is an essential skill in critical care nursing practice. Studies have proposed that positive patient outcomes are linked to expert judgments in a variety of critical care situations; however, little is known about clinical judgments related to specific critical care nursing interventions. This article presents a qualitative nursing research study which examined the cues that expert pediatric critical care nurses used in making clinical judgments about suctioning intubated and ventilated, critically ill children. The participants' words and actions attest that the 'sensing' and 'thinking' of the process of cue use, are interwoven with, and integral to, the 'doing,' which is the process of skilled performance.

Re-Designing State Mental Health Policy to Prevent the Use of Seclusion and Restraint

: The members of the National Association of State Mental Health Program Directors (NASMHPD) believe that seclusion and restraint, including "chemical restraints," are safety interventions of last resort and are not treatment interventions. Seclusion and restraint should never be used for the purposes of discipline, coercion, or staff convenience, or as a replacement for adequate levels of staff or active treatment. The use of seclusion and restraint creates significant risks for people with psychiatric disabilities. These risks include serious injury or death, retraumatization of people who have a history of trauma, and loss of dignity and other psychological harm. In light of these potential serious consequences, seclusion and restraint should be used only when there exists an imminent risk of danger to the individual or others and no other safe and effective intervention is possible. (Endorsed by the State Mental Health Directors, July 13, 1999). (NASMHPD 1999, NASMHPD Position Statement on Seclusion and Restraint. Alexandria, VA: National Technical Assistance Center for State Mental Health Planning.).

[About the use of seclusion in psychiatry: the patients' point of view]

In this study of psychiatric inpatients' perceptions of the seclusion-room experience, 67 admitted inpatients were interviewed during 6 Months within 3 days of the experience, and 24 hours after. A 35-items semistructured interview schedule was used to obtain information on six research questions. Subjects' perception of the reasons for their seclusions varied greatly from perceptions of staff members. Findings implied that for some patients seclusion may have been unnecessary, but for others it was beneficial. Subjects who reported out-of-control impulses or pathological intensity of relationships prior to seclusion and who showed positive change in mood, behavior, or thinking toward staff and/or other patients during or after seclusion seem to have benefited from the experience. Seclusion is a common practice in most psychiatric inpatient settings. The reported incidence of seclusion varies from 4% to 66% of admissions to psychia-tric facilities. But seclusion is controversial. Opponents of seclusion have based their arguments on a concern for the rights of mental patients and a dedication to treat patients in the least restrictive environment. Proponents of seclusion have based their arguments on the theoretical benefits of isolation and the reduction of external stimuli. However, little information about the psychiatric patients experience before, during and after seclusion is currently available. The purpose of this exploratory descriptive study is to gather information on psychiatric patients' perceptions of their seclusion-room experiences, their experiences immediately before and after seclusion, and how they thought these experiences affected them or others. Subjects and staff described the reasons for seclusion differently. For example, subjects described situations leading up to seclusion, but staff described aggressive behavior justifying seclusion. Yet, almost all reasons provided by both groups involved subjects' out-of-control impulses or problems in relationships. The physical, behavioral, and emotional responses of patients to seclusion have been the subject of both observation and more formal investigation. In a study of 263 seclusion episodes, Gerlock and Solomons (1983) noted that 83% of the patients evidenced disturbed behavior at the initiation of seclusion and only 23% did so on release. In a study of the use of the quiet room on a children's unit, Joshi et al. (1988) observed that 92% of the patients who were agitated when placed in the quiet room were calm on release and that 79% were able to rejoin group activities. As for nonempirical investigations, Gair et al. (1965) observed no ill effects (such as fear, withdrawal, or disorganization) and an improvement in inner controls as a result of the use of seclusion on a children's unit. Way and Banks (1990) cautioned against the side effects of humiliation, disorientation, and medical complications of restraint and seclusion in the elderly. As previously noted, many re-presentatives of the psychiatric consumer/survivor movement have characterized seclusion as an extraordinarily traumatic intervention. It is therefore important to examine empirical studies of the emotional effects of this intervention on patients. Perhaps the best-known study is that of Wadeson and Carpenter (1976), which involved 62 mostly unmedicated patients on an NIMH research unit with a seclusion rate of 66%. Patients were asked to draw their experiences and feelings connected with their illness and treatment in three art sessions (2 weeks after admission, 2 weeks before discharge, and 1 Year later). Thirty-three percent of the patients drew the seclusion experience. Their art work and their discussions of it revealed negative feelings (fear, estrangement, hostility, retaliation, guilt, paranoia, bitterness) as well as sadomasochistic conflicts and comforting hallucinations (possibly as a response to sensory deprivation). Several other studies have investigated patients' emotional responses to seclusion. Binder and Mac Coy (1983) conducted semistructured interviews with 24 patients who had been secluded. Thirteen of the 24 patients had no idea or a false idea as to why they had been secluded, 22 were unaware that staff checked on them every 15 minutes, and 13 felt that there was nothing good about the experience. Ne-vertheless, half of the 24 patients felt that the intervention had been necessary and about half felt that it would not adversely affect their attitudes toward treatment. Plutchik et al. (1978) investigated the perceptions of seclusion of patients who had or had not been secluded. Patients who had not been secluded felt safer when they saw others being secluded. Patients who had been secluded felt angry when others were secluded and bored and angry while in seclusion, but the majority felt that seclusion helped calm them down. Patients accurately perceived the precipitants of seclusion. Plutchik et al. also looked at staff perceptions. They found that although most staff felt that seclusion was beneficial to patients, professional staff had the most "regrets" about it. Patients accurately estimated and staff significantly underestimated the average duration of seclusion. Joshi et al. (1988) noted that 14% of children who had been secluded on their unit were angry and 17% were sad while they were in seclusion. Sheridan et al. (1990) observed a 2:1 ratio of negative-to-positive attitudes toward seclusion among patients interviewed at a VA hospital. They also noted that patients' attitudes toward initial seclusion had no effect on subsequent seclusion rates. Thus, although it appears to be reasonably well-established that seclusion "works", i.e., it provides an effective means for preventing injury and reducing agitation, it is at least equally well-established that this procedure can have serious deleterious physical and (more often) psychological effects on patients.

Reducing Seclusion & Restraint Use in Mental Health Settings: Core Strategies for Prevention

1. The use of seclusion and restraint (S/R) is traumatizing to consumers and staff, interrupts the therapeutic process, and is not conducive to recovery. 2. Six effective strategies to reduce S/R use have been identified and are low cost, easily replicable, and publicly available. 3. Organizations that wish to reduce S/R use need to embrace a prevention approach, follow the tenets of continuous quality improvement, and develop a reduction plan individualized for that facility. 4. Highly visible, consistent, and effective organizational leadership appears to be the most significant and critical component in any successful S/R reduction initiative.

Close-observation areas in acute psychiatric units: a literature review

Close-observation areas in Australian inpatient psychiatric units are locked areas usually within an open ward. Despite patient acuity, and the inherent difficulties in this area, little has been written that addresses either the processes or goals of containing patients, the role of nurses, or the skills involved. This paper examines the literature related to close-observation areas and argues that they are highly demanding of expert psychiatric nursing skills. Nurses need to advocate for humane, well-resourced areas, staffed with highly skilled nurses in order to fulfil the obligations of the national nursing and mental health service standards and to reduce the deleterious effects of hospitalization on patients.

Critical thinking and clinical decision making in critical care nursing: a pilot study

OBJECTIVE

This pilot study examined the relationship of education level, years of critical care nursing experience, and critical thinking (CT) ability (skills and dispositions) to consistency in clinical decision making among critical care nurses. Consistency was defined as the degree to which intuitive and analytical decision processes resulted in similar selection of interventions in tasks of low and high complexity.

DESIGN

The study was nonexperimental and correlational.

SAMPLE

Critical care nurses (n = 54) from adult critical care units in 3 private teaching hospitals. The majority of nurses held a BSN or MSN and had an average of 9 years of direct clinical experience in the care of the critically ill.

RESULTS

Decision-making consistency decreased significantly between low-complexity and high-complexity tasks. Both intuitive and analytical decision processes produced clear intervention selections in the low-complexity task, although the analytical process resulted in a more complete specification of interventions. In the high-complexity task, however, only the intuitive process resulted in a clear, plausible, and safe specification of interventions. Education and experience were not related to CT ability, nor was CT ability related to decision-making consistency. Only greater years of critical care nursing experience increased the likelihood of decision-making consistency.

CONCLUSIONS

Overall, intuitive decision processes resulted in more clinically consistent selection of interventions across tasks. More investigation is needed to examine the influence of decision heuristics, and the conceptualization and measurement of CT abilities among practicing nurses.

A synthesis of what we know about the use of physical restraints and seclusion with patients in psychiatric and acute care settings: 2003 update

PURPOSE

This article is an update of the January 19, 2000, Volume 7, Number 2 article of the synthesis of research findings on the use of restraint and seclusion with patients in psychiatric and acute care settings.

CONCLUSIONS

The little that is known about restraint/seclusion use with these populations is inconsistent. Attitudes and perceptions of patients, family, and staff differ. However, all patients had very negative feelings about both, whether they were restrained/secluded or observed by others who were not restrained. The reasons for restraint/seclusion use vary with no accurate use rate for either. What precipitates the use of restraint/seclusion also varies, but professionals claim they are necessary to prevent/treat violent or unruly behavior. Some believe seclusion/restraint is effective, but there is no empirical evidence to support this belief. Many less restrictive alternatives have been tested with varying outcomes. Several educational programs to help staff learn about different ways to handle violent/confused patients have been successful.

IMPLICATIONS

Until more is known about restraint/seclusion use from prospective controlled research, the goal to use least restrictive methods must be pursued. More staff educational programs must be offered and the evaluation of alternatives to restraint/seclusion pursued. When seclusion/restraint is necessary, it should be used less arbitrarily, less frequently, and with less trauma. As the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Health Care Financing Administration (HCFA) have prescribed, "Seclusion and restraint must be a last resort, emergency response to a crisis situation that presents imminent risk of harm to the patient, staff, or others" (p. 25) [99A].

Psychiatric nurses' views on criteria for psychiatric intensive care: acute and intensive care staff compared

AIM

To explore and investigate differences between the views of qualified nurses working in psychiatric intensive care units (PICUs) and acute care wards on which patients are appropriate for PICU care.

BACKGROUND

Previous research on the area of psychiatric intensive care highlights the great differences that exist in all aspects of service provision, from unit size and staffing levels to treatment approaches and physical environment. One of the most common areas of controversy is the type of client behaviour that warrants admission to the PICU.

METHOD

Structured interviews of 100 qualified nursing staff (in the London area, England) working on either acute or PICU wards were used to gather data on appropriate and inappropriate referral to PICUs. Comments made during the course of the interviews were also collected and subjected to content analysis.

FINDINGS

There was evidence to support the hypothesis that acute ward staff considered patients suitable for PICU care at a lower level of risk than PICU staff thought appropriate. In comparison to acute ward nurses, those working in PICUs attended to a broader range of factors when considering suitability for admission to PICU. Appropriate reasons for transfer fell into five groups: risk to others; risk of intentional harm to self; risk of unintentional harm to self; therapeutic benefit from the PICU environment; and legitimate acute ward care problem. Inappropriate reasons for transfer fell into four groups: low risk to others and/or self; illegitimate acute admission care problems; patient belongs elsewhere; policy issues.

CONCLUSION

The study opens up a range of issues not previously studied in relation to the use of PICUs and the intricate relationship of this use with the available acute care wards and other services. These findings and their implications for the care of acute and disturbed psychiatric patients are discussed.

Limit-setting and decision-making in the management of aggression

BACKGROUND

Several published research studies have suggested that inpatient aggression against nursing staff may be directly precipitated by common nurse-patient interactions. This study sought to examine the structure of nurses' judgements in situations of conflict.

METHOD

Seventy practising United Kingdom psychiatric nurses were presented with a number of conflict scenarios and were asked to rate a range of intervention options for each scenario according to how appropriate they perceived those interventions to be. Their responses were analysed using multidimensional scaling techniques.

RESULTS

The results suggest that issues associated with limit setting and autonomy were perceived as most important by the nurses and that these issues are most likely to lead to disagreements in judgement between nurses of different status. Nurses of higher grades (levels) showed a significantly greater preference for respectful and autonomy-confirming interventions than their more junior nurses. These results have training and policy implications and further research should examine the effects of such nursing judgements on patient care.

Through the eye of the beholder: to seclude or not to seclude

The objective of this study is to provide new knowledge and understanding of the decision making used throughout the seclusion process. Seven mental health nurses and one doctor were each interviewed within 48 hours of making the decision to seclude a patient. The interviews were analysed using content analysis. This study provides valuable information regarding factors that are central to, and/or influence, the decision-making process surrounding seclusion. More importantly, the results demonstrate that seclusion is initiated only when all other less restrictive patient management strategies have proven to be unsuccessful with the patient.

HOVIS -- The Hertfordshire/Oxfordshire Violent Incident Study

Violence in psychiatric inpatient units is a major and growing problem. Research interest has primarily focussed on patient characteristics. The role of staff factors and the antecedents of violent incidents has been neglected, despite the fact that staff factors and behaviour may be more readily amenable to change than patient characteristics. The HOVIS study sought to obtain the views of a sample of mental health nurses in current clinical practice about staff-related factors, which they perceive to contribute to, or protect against, the occurrence of violent incidents. A total of 108 nurses working in psychiatric acute admission, intensive care and low secure units, in two NHS Trusts were interviewed using a specially designed semistructured interview schedule. These nurses identified a variety of behaviours, clinical skills, personal characteristics and interpersonal skills that they believe impact on the occurrence of violent incidents. These findings are discussed in relation to their possible training and managerial implications.

Legal and ethical aspects of seclusion: an Australian perspective

The debate about the appropriateness of seclusion as a nursing practice in inpatient settings in the 21st century continues, with powerful and often emotive arguments from those who view it as an anachronistic and punitive form of ward management, and from others who see it as a useful emergency measure to protect individuals from imminent harm. This is the first paper, however, to focus on legal and ethical issues in relation to the use of seclusion, with policies and practices in Australian psychiatric institutions viewed within the context of worldwide trends. The interplay of ethical principles and international mental health law has encouraged a move towards the provision of care and treatment of the disturbed psychiatric patient within the least restrictive environment, supposedly reducing the potential for the inappropriate use of control mechanisms. Nevertheless, current legislation can be seen to preserve the status quo because it legitimizes seclusion as an acceptable nursing practice, albeit within given parameters, thereby defusing the imperative to promote the reduction and abolition of psychiatric control mechanisms and seek new possibilities in mental health care.

Developing a restraint-reduction program for child/adolescent inpatient treatment

TOPIC

Meeting mandated guidelines to reduce, if not eliminate, the use of restraints with children and adolescents hospitalized on inpatient psychiatric units.

PURPOSE

To present eight promising options for restraint reduction with inpatient children and adolescents, and the research that supports their efficacy.

SOURCES

Review of the literature.

CONCLUSION

By combining what is known about child/adolescent restraint use with restraint-reduction research in the adult field, several options for restraint reduction can be derived.

Clinical decision making in nursing: theoretical perspectives and their relevance to practice

AIM OF PAPER

This paper is a response to Thompson's paper 'A conceptual treadmill: the need for a middle ground in clinical decision making theory' published in the Journal of Advanced Nursing in 1999.

SUMMARY OF CONTENT

This author agrees with his main recommendations, which are to seek a middle ground in the current polarized debate over clinical decision making in nursing, and to draw upon Hammond's Cognitive Continuum theory to do so. The theoretical background is sketched out, and the implications of these recommendations are analysed against this. It is argued that nurses now need to move the academic debate forward in such a way as to make serious impact on developing and improving practice. Cognitive continuum theory, in the way in which it focuses on practice, holds considerable potential to assist this move.

CONCLUSION

Drawing on cognitive continuum theory necessarily leads to consequences which are not addressed in Thompson's paper: namely a need to consider the quality of nursing decisions, and a willingness to consider approaches to decision making which have been neglected or criticised by nurses. These consequences are explored here, and the implications of adopting this approach for nurses are outlined.

Faulty assumptions associated with the use of restraints with children

TOPIC

The use of restraints in nursing and other professions has a long and troubling history, particularly in psychiatric settings. No research evidence has demonstrated restraints to be therapeutically effective. A number of faulty assumptions appear to support the continued practice of this unproven and potentially dangerous intervention.

PURPOSE

To present and refute several faulty assumptions using the empirical literature and theory, and to discuss alternatives based on the developmental-ecological theoretical framework for responding to crises in children.

SOURCES

Extant empirical literature.

CONCLUSION

Alternatives to restraints must be investigated and developed to replace the current reactive, crisis-management orientation of practice.

Nursing Staff's Attitudes Toward Seclusion & Restraint

1. Staff preferred to treat patients as they themselves wanted to be treated. 2. More than one third of respondents did not view seclusion and restraint use as a time for a therapeutic intervention. 3. If staff are practicing from their belief patterns, they will choose interventions to avoid use of seclusion and restraint. 4. The majority of respondents preferred using medication to treat out-of-control behavior because they considered it less restrictive.