Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends

Novel Approaches Needed: An Experimental Study with an Alternative to Mechanical Restraint

Despite many calls to reduce or eliminate the use of mechanical restraint, it is still widely used in many countries. Studies using patient interviews have a very clear message: Patients experience mechanical restraint as the most humiliating intervention. There seems to be a lack of alternatives for violent patients if all other approaches to prevent the use of coercion have failed. We developed a method using 30 kg bags, originally designed for fitness purposes, to be attached to a patient's wrist or ankle under 1:1 supervision. The method was tested with 10 experienced nurses and de-escalation trainers. A video was made and presented to six outpatients who had previously experienced mechanical restraint. All participants were interviewed. Transcribed interviews were analysed using qualitative content analysis. All participants approved of the method as a milder and less humiliating alternative to mechanical restraint. The nurses' main concerns were the risk of falls and the use of the bags as weapons. The latter could be controlled by using an additional bag. Patients were generally positive, especially if there was a history of abuse. The method should be further developed to replace at least some mechanical restraints. As with all 'milder means', care should be taken to really replace restraint and not to introduce additional coercion.

A systematic review of interventions to reduce mechanical restraint in adult mental health inpatient settings

Mechanical restraint is a commonly used restrictive practice worldwide, although reducing its use is an international priority. Interventions to reduce mechanical restraint are needed if reducing mechanical restraint is to succeed. Therefore, this systematic review aimed to examine evaluated evidence-based interventions that seek to reduce the incidence of and/or time in mechanical restraint in adult mental health inpatient settings. The JBI framework was used to guide this systematic review. The search strategy included peer-reviewed primary research literature published between 1999 and 2023. Two authors independently conducted the systematic search, selection process and data extraction process. Forty-one studies were included in this review. Using content analysis, we grouped interventions into four categories: (I) calm-down methods, (II) staff resources, (III) legal and policy changes and (IV) changing staff culture. Interventions to reduce mechanical restraint in adult mental health inpatient settings have shown some promise. Evidence suggests that a range of interventions can reduce the incidence of and/or time in mechanical restraint. However, controlled trials were lacking and consensus was lacking across studies. Furthermore, specific findings varied widely, and reporting was inconsistent, hampering the development of interventions for this issue. Further research is needed to strengthen the evidence base for reducing mechanical restraint in mental health inpatient settings.

Exploring psychiatric patient restraints: Balancing safety, ethics, and patient rights in mental healthcare

Restraint, often linked with limiting an individual's freedom of movement, has become a focal point of extensive discussion and evaluation within the realm of mental healthcare. Striking a delicate balance between ensuring individual safety and minimizing reliance on restraint methods poses a significant challenge. In mental health inpatient settings, the prevalent forms of restraint encompass physical, chemical, environmental, and psychological methods. Paradoxically, the consequences of employing restraint can be severe, ranging from injuries and cognitive decline to sedation and, in extreme cases, fatalities. This paper seeks to offer a nuanced exploration of the landscape surrounding psychiatric patient restraints, considering both global perspectives and specific insights from the Indian context. The guidelines outlined in India's Mental Healthcare Act of 2017, which governs the use of restraint on individuals suffering with mental illnesses, are also examined in detail.

Dual harm: Violent behaviour to others and self-harm behaviour in adults compulsorily admitted to a Dutch psychiatric hospital

BACKGROUND

Verbal and physical violence in psychiatric hospitals can have harmful consequences for staff members, such as physical injury, traumatisation, and sick leave, and they often accompany involuntary admission. Harm to others may co-occur with self-harm, i.e., dual harm. However, little is known about the association between dual-harm and violent behaviour towards staff members and its clinical outcomes, such as seclusion and rapid tranquilisation after involuntary admission to a psychiatric inpatient unit.

METHOD

A convenience sample of patients admitted involuntarily (N = 384; mean age = 48.03, SD = 19.92) between January 2016 and December 2019 in Western Brabant, the Netherlands, was used to design a retrospective file audit. Distinct harm groups, marked by the presence/absence of self- and/or other-harm, were investigated using multivariate linear regression modelling on the seriousness of violent acts and the total length of admission. Logistic regression analyses were used to study the association between harm groups and the administration of rapid tranquilisation, seclusion, and extended involuntary admissions.

RESULTS

Several harm groups were identified, including self-harm only, other-harm only, and dual-harm groups. Psychiatric patients admitted to the hospital because of (the risk of) violence towards others had a higher risk of violent incidents during admission and some restrictive measures. In a subgroup of patients with psychotic disorders, patients with dual harm committed the most serious violent incidents compared to those in the other harm groups.

CONCLUSION

Distinct harm groups were identified in a sample of involuntarily admitted patients. In a general adult psychiatric setting, patients at risk for violent behaviour, especially dual-harm patients, should be identified and monitored as part of the risk assessment. Future research is needed to explore more clinical correlates in the proposed distinction between harmful groups and to assess long-term prognosis.

Characteristics and correlates of seclusion and mechanical restraint measures in a Parisian psychiatric hospital group

Introduction

Seclusion or restraint (S/R) are last-resort measures used in psychiatry to ensure the safety of the patient and the staff. However, they have harmful physical and psychological effects on patients, and efforts to limit their use are needed. We describe the characteristics and correlates of S/R events in four Parisian psychiatric centers.

Methods

Within a 3-month period, November 5, 2018 to February 3, 2019, we recorded data for patients experiencing an S/R measure as well as characteristics of the measures. We studied the mean duration of a S/R event, the time between hospital admission and the occurrence of the event, as well as correlates of these durations. We also examined factors associated with use of a restraint versus a seclusion measure.

Results

For the 233 patients included, we recorded 217 seclusion measures and 64 mechanical restraints. Seclusion measures mostly occurred after the patient's transfer from the emergency department. The duration of a seclusion measure was about 10 days. Patients considered resistant to psychotropic treatments more frequently had a longer seclusion duration than others. The mean duration of a mechanical restraint measure was 4 days. Male sex and younger age were associated with experiencing mechanical restraint.

Discussion

S/R measures mostly occur among patients perceived as resistant to psychotropic drugs who are arriving from the emergency department. Developing specific emergency department protocols might be useful in limiting the use of coercive measures.

Use of coercion in mental healthcare services in Nigeria: Service providers' perspective

BACKGROUND

There is increasing advocacy to reduce coercive practices in mental healthcare. Little research has been done on the topic in developing countries.

AIMS

To explore what mental health professionals in Nigeria think about coercion, why it is used, and what contextual factors influence its use in mental healthcare services.

METHODS

Semi-structured interviews were carried out with 16 doctors and 14 nurses from two psychiatric hospitals in two regions of Nigeria. The audio-recorded interviews were analyzed thematically with the aid of MAXQDA software.

RESULTS

Three broad categories relating to the perception of, reasons for, and barriers/facilitators to the use of coercion were derived. Coercion was viewed as being for the best interests of patients, a means to an end, and effective for achieving desired outcomes. Safety was both a reason to use a coercive measure and a deterrent to using specific coercive measures thought to be unsafe. The socio-cultural context, obsolete mental health legislation, staff shortages, and attitudes were factors influencing the use of coercion in mental healthcare.

CONCLUSION

Coercion was perceived to be ultimately beneficial in mental health practice. There is need for a new mental health legislation and more resources for mental health care in Nigeria to address the problem of coercion.

Comparison of coercive practices in worldwide mental healthcare: overcoming difficulties resulting from variations in monitoring strategies

BACKGROUND

Coercive or restrictive practices such as compulsory admission, involuntary medication, seclusion and restraint impinge on individual autonomy. International consensus mandates reduction or elimination of restrictive practices in mental healthcare. To achieve this requires knowledge of the extent of these practices.

AIMS

We determined rates of coercive practices and compared them across countries.

METHOD

We identified nine country- or region-wide data-sets of rates and durations of restrictive practices in Australia, England, Germany, Ireland, Japan, New Zealand, The Netherlands, the USA and Wales. We compared the data-sets with each other and with mental healthcare indicators in World Health Organization and Organisation for Economic Cooperation and Development reports.

RESULTS

The types and definitions of reported coercive practices varied considerably. Reported rates were highly variable, poorly reported and tracked using a diverse array of measures. However, we were able to combine duration measures to examine numbers of restrictive practices per year per 100 000 population for each country. The rates and durations of seclusion and restraint differed by factors of more than 100 between countries, with Japan showing a particularly high number of restraints.

CONCLUSIONS

We recommend a common set of international measures, so that finer comparisons within and between countries can be made, and monitoring of trends to see whether alternatives to restraint are successful. These measurements should include information about the total numbers, durations and rates of coercive measures. We urge the World Health Organization to include these measures in their Mental Health Atlas.

Estimating costs of bedside assessment by a judge in each case of mechanical restraint in Germany after new legislation

Background

In 2018, the German Federal Constitutional Court decided that mechanical restraint is the most intrusive coercive measure and its use requires a judge's decision after bedside assessment if lasting longer than 30 min. Subsequently, legal changes were realized. The objective of our study was to determine the number of saved coercive episodes and saved hours in seclusion or restraint in 2019 compared to the average of the previous years, 2015-2017, as well as costs per saved episode, hour, and case saved from any coercive measure.

Methods

We used data from the Baden-Wuerttemberg case registry for coercive measures, covering all 32 psychiatric hospitals of the Federal State and 435,767 admissions in the study period. Time expenditure was calculated as 3.5 h with an average of 51.95 € per working hour on the side of the justice system and 1.5 h (45.94 €/h) on the side of the hospital per case.

Results

The number of coercive episodes decreased by 10.0% from 28,181 (average 2015-2017) to 25,371 (2019). The number of hours in seclusion or restraint decreased by 17.9% from 321,956 (2015-2017) to 264,423 (2019). This resulted in the cost of 872.33 € per saved episode and 42.61 € per saved hour in seclusion or restraint.

Conclusion

Given the correctness of our estimations, saving 1 h in coercion by less than 1 h of an expert's work might be justified from an ethical and economic perspective.

Bringing together the World Health Organization's QualityRights initiative and the World Psychiatric Association's programme on implementing alternatives to coercion in mental healthcare: a common goal for action

BACKGROUND

Stakeholders worldwide increasingly acknowledge the need to address coercive practices in mental healthcare. Options have been described and evaluated in several countries, as noted recently in major policy documents from the World Health Organization (WHO) and World Psychiatric Association (WPA). The WHO's QualityRights initiative promotes human rights and quality of care for persons with mental health conditions and psychosocial disabilities. A position statement from the WPA calls for implementation of alternatives to coercion in mental healthcare.

AIMS

We describe the engagement of both the WHO and WPA in this work. We discuss their mutual aim to support countries in improving human rights and quality of care, as well as the differences between these two organisations in their stated goals related to coercion in mental healthcare: the WHO's approach to eliminate coercion and the WPA's goal to implement alternatives to coercion.

METHOD

We outline and critically analyse the common ground between the two organisations, which endorse a similar range of rights-based approaches to promoting non-coercive practices in service provision, including early intervention in prevention and care and other policy and practice changes.

RESULTS

Advocacy and action based on an agreed need to find practical solutions and advances in this area have the power to build consensus and unify key actors.

CONCLUSIONS

We conclude that persons with lived experience, families, mental health professionals and policy makers are now coming together in several parts of the world to work toward the common goals of improving quality, promoting human rights and addressing coercion in mental health services.

Ambulance personnel use of coercion and use of safety belts in Norway

BACKGROUND

Providing health care in a moving vehicle requires different considerations regarding safety than in other settings. Use of seatbelts are mandatory, and during ambulance transport patients are fastened to the stretcher with safety straps. However, patients who wriggle out of, or unfasten, their safety straps pose a threat to him/herself and escorting personnel in the ambulance compartment in case of an accident. To prevent harm, ambulance personnel sometimes restrain the patient or unfasten their own seatbelts to keep the patient safe on the stretcher. The prevalence of coercive measures, and the relationship between the use of mechanical restraints comparable to coercion and seatbelt use, are scarcely investigated. Use of coercion normally requires a specific statutory basis. However, coercive measures needed to ensure safety in a moving vehicle while providing healthcare is hardly discussed in the literature. The aim of this study is to explore the use of coercion in ambulance services, the use of safety belts among escorts in situations where they need to keep the patient calm during transportation, and to analyse the relationship between safety belt non-compliance and coercion in these situations.

METHODS

This is a retrospective, cross-sectional study using a self-administered, online survey aiming to investigate the use of coercion and use of seatbelts during ambulance transport. Approximately 3,400 ambulance personnel from all 18 Health Trusts in Norway were invited to participate between Oct 2021 and Nov 2022. Descriptive analyses were used to describe the sample and the prevalence of findings, while multiple linear regressions were used to investigate associations.

RESULTS

Altogether, 681 (20%) ambulance personnel completed the survey where 488 (72.4%) stated that they had used coercion during the last six months and 375 (55.7%) had experienced ambulance personnel or escorting personnel working with unfastened seatbelts during transport. The majority of respondents experienced coercion as being unpleasant and more negative feelings were associated with less use of seatbelts.

CONCLUSIONS

Coercion seems to be used by ambulance personnel frequently. For the study participants, keeping the patient securely fastened was prioritized above escorting personnel's traffic safety, despite feeling uncomfortable doing so. Because coercive measures have negative consequences for patients, is associated with negative feelings for health personnel, and is not discussed ethically and legally in relation to the prehospital context, there is an urgent need for more research on the topic, and for legal preparatory work to address the unique perspectives of the prehospital context in which traffic safety also is an important factor.

Zero Tolerance for Coercion? Historical, Cultural and Organisational Contexts for Effective Implementation of Coercion-Free Mental Health Services around the World

Coercion of service users/patients when receiving care and treatment has been a serious dilemma for mental health services since at least the 18th century, and the debate about how best to minimise or even eradicate compulsion remains intense. Coercion is now, once again and rightly, at the top of the international policy agenda and the COST Action 'FOSTREN' is one example of a renewed commitment by service user advocates, practitioners and researchers to move forward in seriously addressing this problem. The focus of service improvement efforts has moved from pure innovation to practical implementation of effective interventions based on an understanding of the historical, cultural and political realities in which mental health services operate. These realities and their impact on the potential for change vary between countries across Europe and beyond. This article provides a novel overview by focusing on the historical, cultural and political contexts which relate to successful implementation primarily in Europe, North America and Australasia so that policy and practice in these and other regions can be adopted with an awareness of these potentially relevant factors. It also outlines some key aspects of current knowledge about the leading coercion-reduction interventions which might be considered when redesigning mental health services.

Mechanical Restraint in Inpatient Psychiatric Unit: Prevalence and Associated Clinical Variables

Background and Objectives: mechanical restraint (MR) is a controversial issue in emergency psychiatry and should be better studied to implement other alternative therapeutic interventions. The aim of this study was to estimate the prevalence of MR in an Italian psychiatric unit and identify the sociodemographic and clinical characteristics as well as the pharmacological pattern associated with MR. Materials and Methods: all subjects (N = 799) consecutively admitted to an Italian psychiatric inpatient unit were recruited. Several sociodemographic and clinical characteristics were recorded. Results: The prevalence of MR was 14.1%. Males, a younger age, and a single and migrant status were associated with the MR phenomenon. MR was more prevalent in patients affected by other diagnoses and comorbid illicit substance use, in patients with aggressive behaviors, and those that were involuntary admitted, leading significantly to hospitalization over 21 days. Furthermore, the patients that underwent MR were taking a lower number of psychiatric medications. Conclusions: Unfortunately, MR is still used in emergency psychiatry. Future research should focus on the dynamics of MR development in psychiatry, specifically considering ward- and staff-related factors that could help identify a more precise prevention and alternative intervention strategies.

[Coercion in psychiatric hospitalizations in Chile: madness and suffering in the 21st century]

This article reflects on the problem of coercion in Chilean psychiatric hospitalizations from the perspective of users who participate in mental health treatment programs in the public healthcare system. Qualitative research from a hermeneutical epistemic approach was carried out between 2019 and 2020, which included 25 interviews with individuals of both sexes (15 men and 10 women) who had a psychiatric diagnosis. The purpose of this research was to analyze their narratives and critically reframe intervention practices implemented in psychiatric hospitalizations in Chile, which constitute an important space for public health in the country as well as the rights of people with mental health problems. One of the principal findings of the study was that coercive practices still persist in Chile, despite being detrimental to the recovery of mental health care users, representing a negative impact on the quality of life and citizen freedoms of individuals with mental health problems.

Attitudes about Mechanical Restraint Use in Mental Health Hospitalization Services: A Spanish Survey

The aim of this study was to analyze the attitudes of professionals in Mental Health Services throughout Spain who are directly or indirectly involved in the use of mechanical restraint and the barriers perceived to reduce its use. The study involved an online anonymous survey using Google Forms completed by Spanish mental health professionals working with service users; the survey assessed their involvement in and general attitudes and beliefs towards mechanical restraint. The survey was completed by 225 participants. Only 13.30% of the participants considered that mechanical restraint use was never necessary to guarantee the safety of users/staff in dangerous situations. Poor staff training (38.0%) and a lack of resources/staff (34.7%) were the most frequent barriers identified for the reduction of mechanical restraint. In the multivariate analysis, participation in learning programs to prevent the use of mechanical restraint was associated with lower acceptance of the use of mechanical restraint, but the result was barely significant (p = 0.050). A high percentage of mental health staff still consider mechanical restraint use necessary for safety reasons. According to the results, the participants perceived that more staff and resources and better training could reduce the use of mechanical restraint in Mental Health Hospitalization Services.

Psychometric properties of the Italian version of the staff attitude to coercion scale: an exploratory factor analysis

Aims

The current study aimed to validate the Italian version of the Staff Attitude to Coercion Scale (SACS), which assesses mental health care staff's attitudes to the use of coercion in treatment.

Methods

The original English version of the SACS was translated into Italian, according to the back-translation procedure. Subsequently, it was empirically validated by performing an exploratory factor analysis on a sample of 217 mental health professionals (Mean = 43.40 years, SD = 11.06) recruited form Italian general hospital (acute) psychiatric wards (GHPWs), with at least 1 year of work experience (i.e., inclusion criteria).

Results

Results confirmed the three-factor solution of the original version for the Italian version of the SACS, though three items loaded on different factors, compared to the original. The three extracted factors, explained 41% of total variance, and were labeled similarly to the original scale and according to their respective item content, i.e., Factor 1 "Coercion as offending" (items: 3, 13, 14, and 15), Factor 2 "Coercion as care and security" (items: 1, 2, 4, 5, 7, 8, and 9), and Factor 3 "Coercion as treatment" (items: 6, 10, 11, and 12). The internal consistency of the three-factor model of the Italian version of the SACS was assessed through Cronbach's α and yielded acceptable indexes, ranging from 0.64 to 0.77.

Conclusion

The present findings suggest that the Italian version of the SACS is a valid and reliable tool that can be used to assess healthcare professionals' attitudes toward coercion.

Implementation of guidelines on prevention of coercion and violence: baseline data of the randomized controlled PreVCo study

Introduction

The PreVCo study examines whether a structured, operationalized implementation of guidelines to prevent coercion actually leads to fewer coercive measures on psychiatric wards. It is known from the literature that rates of coercive measures differ greatly between hospitals within a country. Studies on that topic also showed large Hawthorne effects. Therefore, it is important to collect valid baseline data for the comparison of similar wards and controlling for observer effects.

Methods

Fifty five psychiatric wards in Germany treating voluntary and involuntary patients were randomly allocated to an intervention or a waiting list condition in matched pairs. As part of the randomized controlled trial, they completed a baseline survey. We collected data on admissions, occupied beds, involuntarily admitted cases, main diagnoses, the number and duration of coercive measures, assaults and staffing levels. We applied the PreVCo Rating Tool for each ward. The PreVCo Rating Tool is a fidelity rating, measuring the degree of implementation of 12 guideline-linked recommendations on Likert scales with a range of 0-135 points covering the main elements of the guidelines. Aggregated data on the ward level is provided, with no patient data provided. We performed a Wilcoxon signed-rank-test to compare intervention group and waiting list control group at baseline and to assess the success of randomization.

Results

The participating wards had an average of 19.9% involuntarily admitted cases and a median 19 coercive measures per month (1 coercive measure per occupied bed, 0.5 per admission). The intervention group and waiting list group were not significantly different in these measurements. There were 6.0 assaults per month on average (0.3 assaults per occupied bed and 0.1 per admission). The PreVCo Rating Tool for guideline fidelity varied between 28 and 106 points. The percentage of involuntarily admitted cases showed a correlation with coercive measures per month and bed (Spearman's Rho = 0.56, p < 0.01).

Discussion

Our findings that coercion varies widely within a country and mainly is associated with involuntarily admitted and aggressive patients are in line with the international literature. We believe that we included a sample that covers the scope of mental health care practice in Germany well.Clinical trial registration: www.isrctn.com, identifier ISRCTN71467851.

Caring Knowledge as a Strategy to Mitigate Violence against Nurses: A Discussion Paper

Violence against nurses is a disturbing trend in healthcare that has reached epidemic proportions globally. These violent incidents can result in physical and psychological injury, exacerbating already elevated levels of stress and burnout among nurses, further contributing to absenteeism, turnover, and intent to leave the profession. To ensure the physical and mental well-being of nurses and patients, attention to the development of strategies to reduce violence against nurses must be a priority. Caring knowledge-rooted in the philosophy of care-is a potential strategy for mitigating violence against nurses in healthcare settings. We present what caring knowledge is, analyze its barriers to implementation at the health system and education levels and explore potential solutions to navigate those barriers. We conclude how the application of models of caring knowledge to the nurse-patient relationship has the potential to generate improved patient safety and increased satisfaction for both nurses and patients.

[The Attitude of the Public Concerning Coercive Measures in Psychiatric Patients]

OBJECTIVE

To examine the attitude of the general public in Basel concerning the use of coercive measures while dealing with psychiatric patients. The common population indirectly governs the use of coercive measures in psychiatry by its stigmatization of people with psychiatric illnesses, and its attitude towards treatment in psychiatry and by local opinion leaders and reactions of social networks.

METHODS

The answers of 1,112 persons from a representative population survey were evaluated. Participants were mailed case vignettes and questionnaires, and asked if they considered involuntary admission, coercive medication, and/or seclusion as acceptable measures in dealing with psychiatric patients.

RESULTS

When symptoms of a psychotic disorder were present, 31.5% approved of at least one coercive measure, with 22% approval in the case of a borderline personality disorder, and 20.7% in the case of alcohol dependency. However, the overall rejection of coercive measures by the general public in Basel was high. The differential approval of the examined coercive measures depending on psychiatric symptoms was in line with professional medical and ethical guidelines.

CONCLUSION

Public attitudes have an indirect influence on the local use of coercive measures and should be included in the specialist psychiatric discourse.

Strengths Model-Based Nursing Interventions for Inpatients in Psychiatric Inpatient Settings Using a Seclusion Room: A Case Series Study

The use of coercive measures in psychiatric inpatient settings has been an important issue for many years. Nursing interventions based on a strengths model could enable a reduction in the use of these measures. This study aimed to describe the practice of nursing interventions using a strengths model for psychiatric inpatients who have been in seclusion for a long time. We also constructed a nursing model to minimize coercive measures. The participants were eight inpatients who had been in seclusion for a long time. Nursing interventions based on a strengths model were implemented in collaboration with nurses from six long-term care units in three psychiatric hospitals in Japan. For 4 of the 8 participants, the seclusion time decreased by 20-45%. However, for another 2, it increased by about 23-34%. An average decrease of 9.6% was observed, and the open observation time increased by 1.4 h per day on the seclusion days. When using this model, the nurses considered the effects of stimulating strengths. We believe this approach may promote inpatients' self-insight. Considering the perspective of stimulus adjustment might be useful for maximizing the positive effects of working on strengths.

Safeguarding patients while implementing mechanical restraints: A qualitative study of nurses and ward staff's perceptions and assessment

AIMS AND OBJECTIVES

To explore nurses' and ward staff's perceptions and assessments of patient care while implementing mechanical restraints.

BACKGROUND

To prevent the risks associated with the use of restraints in psychiatry and ensure safe mental health care, it is necessary to know more about how the nursing staff experiences, comprehends and intervenes in managing patients subjected to coercive measures.

DESIGN

This study employed a qualitative descriptive design, in accordance with the COREQ guidelines.

METHODS

Semi-structured interviews were conducted with 18 nurses and ward staff aged between 22 and 45 years old, who had experience implementing mechanical restraints. Data were digitally audio-recorded and transcribed verbatim. Inductive thematic analysis was conducted using NVivo 12.

RESULTS

The participants believed that mechanical restraints should be used as a last resort and that safeguarding patients during implementation is important; however, their assessments of the patients' physical and mental conditions varied. A clear difference emerged in how management qualified professionals handled situations prior to and during the implementation of mechanical coercive measures.

CONCLUSIONS

The findings emphasise the need to focus on the assessment of patients prior to and during restraint, ensure the quality of safe implementation in a risk-of-harm situation, prioritise competence in education, and practice, and improve management.

RELEVANCE TO CLINICAL PRACTICE

The findings highlight the importance of assessing the physical and mental condition of patients while implementing restraints, as well as aiding the management, nurses and ward staff in tailoring safety procedures.

Environmental Transformations Enhancing Dignity in an Acute Psychiatric Ward: Outcome of a User-Driven Service Design Project

OBJECTIVES

The goal of the current project was to enhance the feeling of dignity for patients in the seclusion unit in an acute psychiatric ward through environmental design changes and to evaluate the effect of the refurbishment.

BACKGROUND

Treating people with dignity is essential in all health-related work and important for our mental health. Hospital architecture and design signal values that can promote dignity. Patients who must spend time in seclusion are at their most vulnerable mental state and the often worn-down like environment can challenge the feeling of dignity. How environmental design can promote dignity in seclusion units have not been studied.

METHODS

To reach suggestions for design changes enhancing dignity, we used service design that included a broad user group. The effect of design changes was evaluated by a questionnaire answered by the nursing staff during a 4-week period pre- and post refurbishment and included a control group.

RESULTS

The design concepts agreed upon were a welcoming atmosphere, contact with nature, room for privacy, close contact with staff, and a designated smoking area inside the unit. The evaluation found that the environmental design changes significantly supported the patients in their situation and the staff in their work.

CONCLUSION

We conclude that dignity design concepts are highly applicable also in an acute psychiatric setting and improve the situation of secluded mental health patients, which is much needed. Findings align with other environmental changes in psychiatric wards that improve the patients' well-being and reduce aggression.

Factors associated with prolonged episodes of mechanical restraint in mental health hospitalization units in Andalusia

WHAT IS KNOWN ON THE SUBJECT?: Risk factors associated with prolonged episodes of mechanical restraint and other coercive measures are understudied. There have been no studies of this phenomenon in the context of the Andalusian public health system. Knowledge about factors associated with prolonged episodes is essential to increase the understanding of this phenomenon and develop strategies to reduce its occurrence. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: In Andalusia, prolonged restraint is still frequent and varies depending on the unit. It is associated with less time since admission, male gender, diagnosis, reason for restraint and the shift on which it was initiated. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Interventions at the level of the units could be necessary to prevent prolonged episodes of mechanical restraint. The results suggest the need for stricter control during the shifts on which restraint starts, especially in the first days after the patient's admission. Preventive risk assessment considering clinical and sociodemographic risk factors could help to reduce prolonged restraint. ABSTRACT: Introduction Factors associated with prolonged episodes of mechanical restraint and other coercive interventions are not clearly established and have been not studied in Andalusia (Spain). Aim To study factors associated with prolonged episodes of mechanical restraint. Method We analysed retrospectively episodes of mechanical restraint (N = 6267, prolonged episode >9.5 hours) in all public mental health hospitalization units (N = 20, 535 beds) that offer health coverage for the autonomous community of Andalusia. The data came from clinical records. A multivariable mixed logistic regression was used. Results In Andalusia, prolonged restraint is still frequent and varies depending on the unit. It is associated with less time since admission, male gender, diagnosis, reason for restraint and the shift on which it was initiated. Discussion The results provide evidence that prolonged episodes largely depend on the unit where they occur and that stricter control and regulation are necessary to prevent prolonged episodes. Implications for practice Interventions at the level of the unit are necessary. Stricter control in the shifts during which there is more risk of prolonged restraint may be necessary, especially in the first days following admission.

Do improved structural surroundings reduce restrictive practices in psychiatry?

BACKGROUND AND OBJECTIVES

There is sparse evidence that modern hospital architecture designed to prevent violence and self-harm can prevent restrictive practices (RP). We examine if the use of RPs was reduced by the structural change of relocating a 170-year-old psychiatric university hospital (UH) in Central Denmark Region (CDR) to a new modern purpose-built university hospital.

METHODS

The dataset includes all admissions (N = 19.567) and RPs (N = 13.965) in the self-contained CDR one year before and after the relocation of the UH. We compare RPs at the UH a year prior to and after relocation on November 16th (November 2017, November 2019) with RPs at the other psychiatric hospitals (RH) in CDR. We applied linear regression analysis to assess the development in the monthly frequency of RPs pre- and post-relocation and examine underlying trends.

RESULTS

At UH, RPs performed decreased from 4073 to 2585 after relocation, whereas they remained stable (from 3676 to 3631) at RH. Mechanical restraint and involuntary acute medication were aligned at both UH and RH. Using linear regression analysis, we found an overall significant decrease in the use of all restrictive practices at UH with an inclination of -9.1 observations (95% CI - 12.0; - 6.3 p < 0.0001) per month throughout the two-year follow-up. However, the decrease did not deviate significantly from the already downward trend observed one year before relocation. Similar analyses performed for RH showed a stable use of coercion.

CONCLUSION

The naturalistic features of the design preclude any definitive conclusion whether relocation to a new purpose-built psychiatric hospital decreased the RPs. However, we argue that improving the structural environment at the UH had a sustained effect on the already declining use of RPs, particularly mechanical restraint and involuntary acute medication.

A systematic review of in-patient psychiatric care for people with intellectual disabilities and/or autism: effectiveness, patient safety and experience

BACKGROUND

An increasing number of children, adolescents and adults with intellectual disabilities and/or autism are being admitted to general psychiatric wards and cared for by general psychiatrists.

AIMS

The aim of this systematic review was to consider the likely effectiveness of in-patient treatment for this population, and compare and contrast differing models of in-patient care.

METHOD

A systematic search was completed to identify papers where authors had reported data about the effectiveness of in-patient admissions with reference to one of three domains: treatment effect (e.g. length of stay, clinical outcome, readmission), patient safety (e.g. restrictive practices) and patient experience (e.g. patient or family satisfaction). Where possible, outcomes associated with admission were considered further within the context of differing models of in-patient care (e.g. specialist in-patient services versus general mental health in-patient services).

RESULTS

A total of 106 studies were included and there was evidence that improvements in mental health, social functioning, behaviour and forensic risk were associated with in-patient admission. There were two main models of in-patient psychiatric care described within the literature: admission to a specialist intellectual disability or general mental health in-patient service. Patients admitted to specialist intellectual disability in-patient services had greater complexity, but there were additional benefits, including fewer out-of-area discharges and lower seclusion rates.

CONCLUSIONS

There was evidence that admission to in-patient services was associated with improvements in mental health for this population. There was some evidence indicating better outcomes for those admitted to specialist services.

What do we know about the experience of seclusion in a forensic setting? An integrative literature review

Seclusion is used in forensic and general mental health settings to protect a person or others from harm. However, seclusion can result in trauma-related harm and re-traumatization with little known about the experience of seclusion for consumers in forensic mental health settings from their perspectives. This article explores consumer experiences of seclusion in forensic mental health settings and explores the differences between female and male experiences of seclusion. Five electronic databases were systematically searched using keywords and variations of experience, attitude, seclusion, coercion, forensic mental health, and forensic psychiatry. Inclusion criteria were original peer-reviewed studies conducted in adult forensic mental health settings reporting data on the experiences of or attitudes towards seclusion. Seven studies met the criteria for inclusion and a quality assessment was undertaken. Results found consumers in forensic mental health settings perceive seclusion to be harmful, a punishment for their behaviour, and largely a negative experience that impacts their emotional health. Some consumers report positive experiences of seclusion. Differences in the experience of seclusion for females and males are unclear. Further research is required to understand the experience of seclusion for women in forensic mental health settings. Identification and consideration of differences in the experience of seclusion for males and females may assist in identifying sex-specific interventions and may inform policy and practices to eliminate or reduce the trauma associated with seclusion use.

PROD-ALERT: Psychiatric restraint open data—analysis using logarithmic estimates on reporting trends

Aims and Methods

Restraint reporting varies, which undermines regulation, obfuscates analyses, and incentivises minimisation. The English Mental Health Units Use of Force Act 2018, “Seni's Law” mandates reporting. This paper analysed open data from all psychiatric and learning disability institutions in England from September 2020 to August 2021. We correlated logarithms of “people restrained per month”, against “bed days” per month and “people under legal mental health detention” per month, per institution. We designated institutions reporting some restraint for at least 11 of 12 months as reporting “completely” and used their trend to infer rates from non-“complete” institutions. Allowance was made for size. Our a priori manual can be shared on request.

Results

Logarithms of people restrained per month and bed-days per month correlated among complete reporters: R² 0.90 (2.s.f). Persons detained per month also correlated with restraint: R² 0.78. “Partial” institutions reported intermittently. “Joiner” institutions reported firstly null, then substantive reporting. “Null” institutions (including the largest) reported no restraint. Precisely-reporting institutions with high inverse variance between months reported similar restraint-rates but less-precise reported lower rates. In institutions reporting no restraint, two independent “true rate” estimations, by bed-days or people detained, correlated across institutions: R² 0.95. Inference from size suggested non-complete reporters restrained 1,774 people in England per month 95% CI (1,449–2,174).

Clinical implications

Restraint remains under-reported. Institutional size explains most restraint variation among complete reporting institutions, 90% of R². Institutional restraint reports can be compared per-bed per-month. Rates of people detained are a useful independent “checking” comparator in England.

An Evidence-Based Educational Intervention for Reducing Coercive Measures in Psychiatric Hospitals: A Randomized Clinical Trial

IMPORTANCE

Investing in health care staffs' education can change the scope of action and improve care. The effectiveness of staff education remains inconclusive.

OBJECTIVE

To examine whether an evidence-based educational intervention for nurses decreases the use of seclusion rooms in psychiatric hospitals compared with usual practice.

DESIGN, SETTING, AND PARTICIPANTS

In this pragmatic, 2-arm parallel, stratified cluster randomized clinical trial, 28 wards in 15 psychiatric hospitals in Finland were screened for eligibility and randomly allocated (1:1). Nurses joined on either intervention (n = 13) or usual practice (n = 15) wards. The intervention was performed from May 1, 2016, to October 31, 2017. The follow-up data for January 1 to December 31, 2017, were collected from hospital registers in 2018. Data analysis was performed October 27, 2021.

INTERVENTIONS

Evidence-based education delivered during 18 months, including 8 months of active education, followed by a 10-month maintenance period.

MAIN OUTCOMES AND MEASURES

The primary outcome was the occurrence of patient seclusion (events per total number of patients).

RESULTS

Of 28 psychiatric hospital wards screened (437 beds and 648 nurses), 27 wards completed the study. A total of 8349 patients were receiving care in the study wards, with 53% male patients and a mean (SD) age of 40.6 (5.7) years. The overall number of seclusions was 1209 (14.5%) in 2015 and 1349 (16.5%) in 2017. In the intervention group, the occurrence rate of seclusion at the ward level decreased by 5.3% from 629 seclusions among 4163 patients (15.1%) to 585 seclusions among 4089 patients (14.3%) compared with a 34.7% increase from 580 seclusions among 4186 patients (13.9%) to 764 seclusions among 4092 patients (18.7%) in the usual practice group. The adjusted rate ratio was 0.86 (95% CI, 0.40-1.82) in 2015 and 0.66 (95% CI, 0.31-1.41) in 2017 (P = .003). However, the number of forced injections increased in the intervention group from 317 events among 4163 patients (7.6%) in 2015 to 486 events among 4089 patients (11.9%) in 2017 compared with an increase in the usual practice group from 414 events among 4186 patients (9.9%) in 2015 to 481 events among 4092 patients (11.8%) in 2017. Seven adverse events were reported.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, the educational intervention had a limited effect on the change of occurrence rate of patient seclusion, whereas the use of forced injections increased. More studies are needed to better understand the reasons for these findings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02724748.

Current trends in restrictive interventions in psychiatry: a European perspective

This article reviews current evidence on the use of coercive measures, including seclusion and restraint, in psychiatric in-patient settings in Europe. There is a particular focus on evidence regarding the use of mechanical restraint. The review seeks to describe when the use of restrictive interventions such as restraint may be necessary, to explore the use of restraint in certain specialist settings and to investigate current laws and European policies on seclusion and restraint. The current rates of restraint in European psychiatric settings are explored, with a discussion of the limitations of the evidence currently available. The article discusses various consequences of seclusion and restraint, potential alternatives to their use and strategies to minimise their use and harm to patients. The use of coercive measures from an international context is considered, to provide context.

Post-incident reviews after restraints-Potential and pitfalls. Patients' experiences and considerations

WHAT IS KNOWN ABOUT THE SUBJECT?: Restraint has negative psychological, physical and relational consequences for mental health patients and care providers. Several countries have implemented seclusion and restraint (S/R) reduction programmes in which post-incident reviews (PIRs) including patients and care providers are one of several strategies. Existing knowledge indicates that PIRs have the potential to contribute to S/R prevention, but knowledge of the patients' perspectives on PIRs is scarce. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper provides in-depth knowledge about patients' experiences of being participants in PIRs after restraint events. Patients experience PIRs to result in being strengthened and developing new coping strategies. The paper reveals pitfalls when planning and conducting PIRs that make patients experience PIRs as meaningless, feel objectified or long for living communication and closeness. The patients' mental state, the quality of the relationships and the services' care philosophies, influence patients' experiences of PIRs as supporting their personal recovery processes or as continuation of coercive contexts. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Patients' vulnerability during the PIRs must be acknowledged. Trusted persons or advocacy must support the patient in the PIR and thus reduce the power-dependence imbalance. The PIR must be conducted in a supportive, non-punishing atmosphere. Patients must influence planning for the PIR concerning time point and participants and themes to be discussed. The PIR forms should be extended to support the patients' empowerment and well-being. ABSTRACT: Introduction Post-incident reviews (PIRs), including patients, nurses and other care providers, following incidents of restraints are recommended in mental health services. Few studies have examined patients' experiences and considerations concerning PIRs. Aim The study aims to explore patients' perspectives on PIRs in relation to how they experience participation in PIRs and further view PIRs' potential for care improvement and restraint prevention. Method We conducted a qualitative study based on individual interviews. Eight current and previous inpatients from two Norwegian mental health services were interviewed. Results The patients experienced PIRs as variations on a continuum from being strengthened, developing new coping strategies and processing the restraint event to at the other end of the continuum; PIRs as meaningless, feeling objectified and longing for living communication and closeness. Discussion PIRs' beneficial potential is extended in the study. The findings highlight however that personal and institutional conditions influence whether patients experience PIRs as an arena for recovery promotion or PIRs as continuation of coercive contexts. Implications for practice We recommend patients' active participation in planning the PIR. PIRs should be conducted in a supportive atmosphere, including trusted persons, emphasizing and acknowledging a dialogical approach.

A two-center pilot study on the effects of clinical ethics support on coercive measures in psychiatry

BACKGROUND

The use of formal coercion such as seclusion, mechanical restraint, and forced medication is one of the most challenging and complex issues in mental health care, on the clinical, the legal, and the ethical level. Clinical ethics support aims at assisting healthcare practitioners in determining the morally most justifiable course of action in these situations. However, the effectiveness of clinical ethics support has hardly been studied so far.

METHODS

Monthly moral case deliberation (MCD) was implemented in two acute wards of two different psychiatric hospitals in Switzerland. Frequency and intensity of coercion was measured on ward level (npatients = 405), and the Moral Attentiveness Scale, Knowledge on Coercion Scale, and Staff Attitudes towards Coercion Scale were applied on healthcare practitioner level (nHP = 46). Pre-post-comparisons were conducted using multi-level modeling where appropriate.

RESULTS

After implementation of MCD, formal coercion was less frequent (particularly seclusion, small effect size; 9.6 vs. 16.7%, p = .034, Cramér's V = .105) and less intense (particularly mechanical restraint, large effect size; 86.8 ± 45.3 vs. 14.5 ± 12.1 h, exact p = .019, r = -.74), and approval for coercive measures among healthcare practitioners was lower when controlling for the number of MCD sessions attended.

CONCLUSIONS

Clinical ethics support such as MCD may be a hitherto underutilized service for the reduction of coercion, complementing existing strategies and programs. Implementing clinical ethics support may help improve quality of care for persons suffering from severe mental illness.

[Documentation, Application and Efforts to Reduce Involuntary Admissions and Coercive Measures - Results from a Nationwide Study on Acute Psychiatric Hospitals in Germany]

OBJECTIVE

This nationwide full census survey investigated the documentation status regarding involuntary admissions and coercive measures in psychiatric hospitals in Germany.

METHODS

As part of the ZIPHER study, a questionnaire survey on the documentation, application and reduction of coercion was conducted (N = 147, response rate = 34.4 %).

RESULTS

The majority of participating hospitals reported a comprehensive documentation of the use of coercion. However, substantial regional differences could be found in this regard as well as for the use of guidelines. The involuntary admission quote was M = 13.4 % (± 10.9). Of those, 33.9 % (± 22.2) were affected by mechanical restraint, 8.9 % (± 17.2) by seclusion, and 11.8 % (± 18.0) by compulsory medication.

CONCLUSION

The regional differences plead for a unification of legal bases and applied practice as well as for a merge of respective data on a nationwide level of the relevant stakeholders.

Physical Restraint Events in Psychiatric Hospitals in Hong Kong: A Cohort Register Study

The need to better monitor coercion practices in psychiatric hospitals has been recognised. We aim to describe how physical restraint events occur in psychiatric hospitals and identify factors associated with physical-restraint use. A cohort register study was used. We analyzed physical restraint documents among 14 wards in two psychiatric hospitals in Hong Kong (1 July and 31 December 2018). In total, 1798 incidents occurred (the rate of physical restraint event 0.43). Typically, physically restrained patients were in early middle-age, of both genders, diagnosed with schizophrenia-spectrum and other psychotic disorders, and admitted voluntarily. Alternate methods for physical restraint were reported, such as an explanation of the situation to the patients, time-out or sedation. A longer period of being physically restrained was associated with being male, aged ≥40 years, having involuntary status, and neurodevelopmental-disorder diagnosis. Our findings support a call for greater action to promote the best practices in managing patient aggression and decreasing the use of physical restraint in psychiatric wards. The reasons for the use of physical restraint, especially for those patients who are admitted to a psychiatric hospital on a voluntary basis and are diagnosed with neurodevelopmental disorders, needs to be better understood and analysed.

The use of coercive measures in a high security setting in Belgium: Prevalence and risk factors

Coercive measures are often used in forensic psychiatric settings as a strategy to manage violent and other problematic behavior. Few studies have been published regarding the use of coercive measures in high security populations. This is the first empirical study on this subject in Belgium. The aim of the present study was to examine the prevalence rates of coercive measures in Flanders' two high security settings and to identify individual patient risk factors for being subjected to a coercive measure. The study included all patients (N = 654) who were admitted in the Forensic Psychiatric Centres of Antwerp or Ghent over a six-year period. Data on the use of coercive measures (seclusion, mechanical restraint, and chemical restraint) were registered prospectively. Several regression analyses were conducted with multiple independent variables. The results show that half of the population (50.3%) was subjected to at least one coercive measure during admission in one of the high security settings. A small subgroup of patients (6.4%) was the subject of half of all coercive measures (50,4%). Seclusion was the most frequently used coercive measure (48.3%), followed by chemical restraint (20.2%). The prevalence rate of mechanical restraint was very low (0.8%) compared to previous research in similar populations. Various individual risk factors were significantly associated with a higher use of coercive measures. Clinical implications are discussed and the importance of developing international standards on recording and reporting on coercive measures is highlighted.

Risk factors associated with use of coercive practices in adult mental health inpatients: A systematic review

WHAT IS KNOWN ON THE SUBJECT?: Coercive practices such as restraint (physically holding a person) or seclusion (containing a person in locked room) are frequently used in mental health care. How often and which specific practices are used is not consistent across different healthcare systems, hospitals or wards. Internationally, there is agreement on the need to monitor and reduce the use of coercive practices. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The reviewed evidence suggests a number of different factors affect a person's risk of experiencing coercive practices, while admitted to a mental health ward. However, there is currently not enough high-quality research evidence to say which factors are most important or how they work to influence the likelihood of a person experiencing coercive practice. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: When carrying out risk assessments, mental health professionals must take into account that a number of different factors are important and explore these with the patient. Care plans aimed at minimizing the use of coercive practices, such as restraint, must be personalized and developed with the individual. ABSTRACT: Introduction Coercive practices, such as physical restraint and seclusion, are a common feature of all mental healthcare systems. However, there is considerable variation in their use, concern about their iatrogenic potential and agreement internationally on the need to monitor and reduce their use. Aims To examine the evidence concerning risk factors associated with use of coercive practices in adults admitted to inpatient psychiatric services. Method A systematic review, consistent with PRIMSA guidelines, of four databases (PsychINFO, Medline, CINHAL and Embase). Peer-reviewed, English language articles from database inception to February 2020 were included. Methodological quality was assessed using the Quality Assessment Tool for Quantitative Studies. Results Twenty studies met inclusion criteria. Risk factors examined in the studies organized around four categories: patient socio-demographic; patient clinical; staff; and organizational factors. Overall, methodological quality of papers was deemed weak, and there was insufficient evidence to support any singular risk factor. Discussion The reviewed evidence suggests risk of coercive practice in inpatient mental health settings is multifactorial. Further research to standardize concept definitions and elucidate the mechanisms behind variance in use is required. Implications for Practice Assessment of patients at risk of coercive practice must take a multifactorial approach.

Relationship between nurses' use of verbal de-escalation and mechanical restraint in acute inpatient mental health care: a retrospective study

Although the use of verbal de-escalation in nursing has been shown to be an effective tool for controlling agitation and avoiding mechanical restraint, there is scarce evidence supporting the use of de-escalation by nurses and factors related to the patients who ultimately receive mechanical restraint. This retrospective study sought to examine the relationship between the use of verbal de-escalation by nurses and the clinical profile of patients who had received mechanical restraint at an acute mental health unit. This study analysed the records of patients who had received mechanical restraint between the years 2012 and 2019. A bivariate analysis was initially performed, followed by multiple logistic regression analysis. A total of 493 episodes of restraint were recorded. Of these, in almost 40% of cases, no prior use of verbal de-escalation was noted. The factors associated with the use of verbal de-escalation by nurses were patients with a history of restraint episodes and patients who previously had been administered medication. Furthermore, episodes of mechanical restraint that occurred later during the admission were also associated with the use of de-escalation. These findings confirm the relevance of early nurse interventions. Consequently, it is important to establish an adequate therapeutic relationship from the start of hospitalization to facilitate getting to know the patient and to enable the timely use of verbal de-escalation, thus avoiding the use of mechanical restraint.

[Effects of the Decision of the German Constitutional Court on mechanical restraint in 2018 : Coercive measures in the psychiatric hospitals in Baden-Wuerttemberg in 2019 compared to the years 2015-2017]

On 23 July 2018 the German Constitutional Court decided that mechanical restraint in psychiatric patients with 5 or 7‑point mechanical restraint lasting longer than 30 min requires a judicial authorization. On the same day, the German Association for Psychiatry and Psychotherapy (DGPPN) published guidelines on the prevention of coercion and violence. Together, this can be considered as the strongest intervention to reduce coercion on a national level worldwide. The registry for coercive measures in the Federal State of Baden-Wuerttemberg, available since 2015 and comprising all 32 hospitals licensed to admit involuntary patients, has made it possible to evaluate the effect of the legal change. We analyzed the mean percentage of patients subjected to coercive measures and the mean cumulative duration of these interventions in ICD-10 diagnostic groups in psychiatric hospitals from 2015 to 2017 compared to 2019 among a total of 438,003 admissions. The percentage of patients subjected to any kind of freedom-restricting coercion (restraint or seclusion) decreased from 6.7% (average 2015-2017) to 5.8% in 2019 (p < 0.001). Effects were strongest in patients with organic (F0) and schizophrenic disorders (F2). The percentage of patients subjected to mechanical restraint decreased from 4.8% to 3.6% in 2019, and the percentage of mechanical restraints less than 30 min increased from 1.8% to 10.5%. Vice versa, the percentage of patients subjected to seclusion increased from 2.9% to 3.3%. The median cumulated duration of restraint and seclusion per affected case decreased from 12.7h to 10.9 h (median). The intervention was probably responsible for a reduction of the percentage of cases subjected to coercive measures by about 13% and a reduction of the duration of these measures per affected case by about 14%.

The association between objective necessity for involuntary treatment as measured during admission, legal admission status and clinical factors in an inpatient psychiatry setting

Involuntary psychiatric admission is a common feature of mental health services around the world, but there is limited research about tools to support clinical assessment of objective necessity for compulsory care. Our study aimed to determine the relationships between objective necessity for involuntary treatment as measured by the Compulsory Treatment Checklist (CTC), legal admission status (voluntary or involuntary) and various clinical parameters (e.g. symptoms, insight) in an Irish inpatient psychiatry setting. The CTC is relatively new tool, developed and described by Brissos et al. (2017) in Portugal and designed to evaluate the necessity for compulsory treatment; its total score ranges from 0 to 50 (with higher scores indicating greater need for involuntary care). In our study, we used validated tools, including the CTC, to perform detailed assessments of 107 adult patients admitted to the acute psychiatry inpatient units of two general hospitals in Dublin, Ireland over a 30-month period. The most common diagnoses were affective disorders (46.7%), schizophrenia and related disorders (27.1%), and personality and behavioural disorders (11.2%). Over a quarter (27.1%) of patients had involuntary legal status. Higher CTC scores were significantly and independently associated with involuntary status (p < 0.001), more positive symptoms of schizophrenia (p < 0.001), and younger age (p = 0.031). The original Portuguese study of the CTC identified an optimal cut-off score of 23.5, which detected compulsory treatment with a sensitivity of 75% and specificity of 93.6% in that sample. In our sample, the optimal cut-off score was 16.5, which detected compulsory treatment with a sensitivity of 82.8% and specificity of 69.2%. We conclude that the CTC is a useful tool not only in Portugal but in other countries too, and that its performance will likely vary across jurisdictions, resulting in different optimal cut-off scores in different countries.

An Educational Intervention to Decrease the Number of Emergency Incidents of Restraint and Seclusion on a Behavioral Health Unit

BACKGROUND

The objective of this study was to implement an educational intervention on an inpatient, behavioral health care unit with the goal of reducing the number of crisis interventions of seclusion or restraint.

METHOD

A quasi-experimental pretest and posttest design using De-escalate Anyone, Anywhere, Anytime training was employed with a focus of an increased understanding of a range of de-escalation techniques to use instead of restraint and seclusion.

RESULTS

A convenience sample of 21 mental health employees participated in the training. The rates of restraint declined from a mean of 6 preintervention to 2 postintervention. The number of seclusions on the designated unit declined from a mean of 4.33 preintervention to a mean of 1.667 postintervention.

CONCLUSION

These data suggest that an educational intervention to increase the knowledge of direct care staff in a broad range of de-escalation techniques resulted in a reduction in the use of restraint and seclusion. Ongoing training for nursing staff may reassure them of the efficacy of alternative methods for dealing with aggressive patients. [J Contin Educ Nurs. 2022;53(2):70-76.].

A Systematic Review of the Effectiveness of Safewards: Has Enthusiasm Exceeded Evidence?

Safewards is intended to be an evidence-based approach to reduce levels of conflict and containment in mental health inpatient settings. A systematic review was carried out to examine whether Safewards is effective in reducing conflict and containment events; and improving ward climate. Searches for articles evaluating the implementation of Safewards was conducted using PsycINFO, PubMed, Web of Science, Cochrane Library and CINAHL. Thirteen studies were included for review after applying inclusion and exclusion criteria. The Quality Assessment Tool for Studies with Diverse Designs (QATSDD) was used to assess study quality and the majority of studies (N = 7) were rated as "moderate" quality. Whilst there is evidence to suggest that Safewards is effective for reducing conflict and containment in general mental health services, there is insufficient high-quality empirical evidence to support its effectiveness in settings beyond this. Further research using robust methodological designs with larger, more representative samples is required in order for the effectiveness of Safewards to be established across the range of contexts in which it is currently being applied.

Effectiveness of De-Escalation in Reducing Aggression and Coercion in Acute Psychiatric Units. A Cluster Randomized Study

OBJECTIVE

Most guidelines for the management of aggressive behavior in acute psychiatric patients describe the use of de-escalation as the first-choice method, but the evidence for its effectiveness is inconsistent. The aim of the study was to assess the effect of verbal and non-verbal de-escalation on the incidence and severity of aggression and the use of physical restraints in acute psychiatric wards.

METHODS

A multi-center cluster randomized study was conducted in the acute wards of all psychiatric hospitals in Slovenia. The research was carried out in two phases, a baseline period of five consecutive months and an intervention period of the same five consecutive months in the following year. The intervention was implemented after the baseline period and included training in verbal and non-verbal de-escalation techniques for the staff teams on experimental wards.

RESULTS

In the baseline study period, there were no significant differences in the incidence of aggressive behavior and physical restraints between the experimental and control groups. The incidence rates of aggressive events, severe aggressive events, and physical restraints per 100 treatment days decreased significantly after the intervention. Compared to the control group, the incidence rate of aggressive events was 73% lower in the experimental group (IRR = 0.268, 95% CI [0.221; 0.342]), while the rate of severe events was 86% lower (IRR = 0.142, 95% CI [0.107; 0.189]). During the intervention period, the incidence rate of physical restraints due to aggression in the experimental group decreased to 30% of the rate in the control group (IRR = 0.304, 95% CI [0.238; 0.386]). No reduction in the incidence of restraint used for reasons unrelated to aggression was observed. After the intervention, a statistically significant decrease in the severity of aggressive incidents (p < 0.001) was observed, while the average duration of restraint episodes did not decrease.

CONCLUSION

De-escalation training is effective in reducing the incidence and severity of aggression and the use of physical restraints in acute psychiatric units.

CLINICAL TRIAL REGISTRATION

[www.ClinicalTrials.gov], identifier [NCT05166278].

"Disruptive Behavior" or "Expected Benefit" Are Rationales of Seclusion Without Prior Aggression

OBJECTIVE

In the Netherlands, seclusion of patients with a psychiatric disorder is a last-resort measure to be used only in the event of (imminent) severe danger or harm. Although aggressive behavior is often involved, seclusions not preceded by aggression also seem to occur. We sought insight into the non-aggressive reasons underlying seclusion and investigated the factors associated with it.

METHOD

We included all patients admitted to a Dutch psychiatric hospital in 2008 and 2009. Seclusions had been registered on Argus-forms, and aggression incidents had been registered on the Staff Observation Aggression Scale-Revised (SOAS-R), inspectorate forms and/or patient files. Determinants of seclusion with vs. without prior aggression were analyzed using logistic regression. Reasons for seclusion without prior aggression were evaluated qualitatively and grouped into main themes.

RESULTS

Of 1,106 admitted patients, 184 (17%) were secluded at some time during admission. Twenty-one (11.4%) were excluded because information on their seclusion was lacking. In 23 cases (14%), neither SOAS-R, inspectorate forms nor individual patient files indicated any aggression. Univariable and multivariable regression both showed seclusion without preceding aggression to be negatively associated with daytime and the first day of hospitalization. In other words, seclusion related to aggression occurred more on the first day, and during daytime, while seclusion for non-aggressive reasons occurred relatively more after the first day, and during nighttime. Our qualitative findings showed two main themes of non-aggressive reasons for seclusion: "disruptive behavior" and "beneficial to patient."

CONCLUSION

Awareness of the different reasons for seclusion may improve interventions on reducing its use. Thorough examination of different sources showed that few seclusions had not been preceded by aggression. The use of seclusion would be considerably reduced through interventions that prevent aggression or handle aggression incidents in other ways than seclusion. However, attention should also be paid to the remaining reasons for seclusion, such as handling disruptive behavior and focusing on the beneficial effects of reduced stimuli. Future research on interventions to reduce the use of seclusion should not only aim to reduce seclusion but should also establish whether seclusions preceded by aggression decrease different from seclusions that are not preceded by aggression.

Measuring Seclusion in Psychiatric Intensive Care: Development and Measurement Properties of the Clinical Seclusion Checklist

Background: Acute psychiatric units in general hospitals must ensure that acutely disturbed patients do not harm themselves or others, and simultaneously provide care and treatment and help patients regain control of their behavior. This led to the development of strategies for the seclusion of a patient in this state within a particular area separated from other patients in the ward. While versions of this practice have been used in different countries and settings, a systematic framework for describing the various parameters and types of seclusion interventions has not been available. The aims of the project were to develop and test a valid and reliable checklist for characterizing seclusion in inpatient psychiatric care. Methods: Development and testing of the checklist were accomplished in five stages. Staff in psychiatric units completed detailed descriptions of seclusion episodes. Elements of seclusion were identified by thematic analysis of this material, and consensus regarding these elements was achieved through a Delphi process comprising two rounds. Good content validity was ensured through the sample of seclusion episodes and the representative participants in the Delphi process. The first draft of the checklist was revised based on testing by clinicians assessing seclusion episodes. The revised checklist with six reasons for and 10 elements of seclusion was tested with different response scales, and acceptable interrater reliability was achieved. Results: The Clinical Seclusion Checklist is a brief and feasible tool measuring six reasons for seclusion, 10 elements of seclusion, and four contextual factors. It was developed through a transparent process and exhibited good content validity and acceptable interrater reliability. Conclusion: The checklist is a step toward achieving valid and clinically relevant measurements of seclusion. Its use in psychiatric units may contribute to quality assurance, more reliable statistics and comparisons across sites and periods, improved research on patients' experiences of seclusion and its effects, reduction of negative consequences of seclusion, and improvement of psychiatric intensive care.

Factors associated with the use of mechanical restraint in a mental health hospitalization unit: 8-year retrospective analysis

WHAT IS ALREADY KNOWN ABOUT THE TOPIC?: Our present understanding of mechanical restraint is heterogenous, largely due to the important differences between countries/regions. In Spain, the use of this restrictive practice is not regulated, nor is its use protocolized. Previous studies that have investigated the impact of organizational factors and changes in these protocols are often short and not conducted within a framework designed to establish a long-term plan for reducing the use of mechanical restraint. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: We demonstrate that the implementation of administrative and protocol changes in our psychiatric unit significantly reduced the use of mechanical restraint, thus laying the foundations for a regulatory framework. Our analysis shows that the profile of patients who require mechanical restraint is highly variable, but that certain clinical and institutional aspects within the framework of a long-term plan for the reduction in mechanical restraint can be targeted with long-lasting positive effects. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Organizational changes focussed on training staff, promoting family support and requiring the registration and close monitoring of episodes empower the role of the nursing staff in the prevention, monitoring and regulation of mechanical restraint. ABSTRACT: Introduction Mechanical restraint is a controversial restrictive practice to manage agitation or violent behaviour. Numerous studies have evaluated the factors and organizational changes that influence on mechanical restraint, but only for short time periods. None of those studies have assessed the effects of measures applied within the framework of a long-term plan to reduce the use of mechanical restraint. Given the lack of specific legislation in Spain, more data are required for its proper regulation. Aim/Question To evaluate the risk factors associated and the impact of specific measures designed to minimize the application of mechanical restraint in an acute mental health unit over an 8-year period and previous observation of 5 years. Methods Cross-sectional study based on a retrospective analysis of mechanical restraint records. We compared admissions requiring ≥one episode of restraint versus admissions not requiring this coercive measure. Results Between 2007 and 2014, 412 admissions (12%) required mechanical restraint. The data show that the measures applied in the previous five years had significantly reduced the total hours of restraint per semester. The factors associated with admissions requiring mechanical restraint were involuntary, unscheduled and longer admissions. The best predictor of restraint was involuntary admission (OR = 6.37), followed by the diagnosis of personality disorder (OR = 5.01). Discussion Identification of the factors associated with mechanical restraint would allow for early detection strategies. Our results provide additional evidence on the usefulness of organizational changes to reduce coercive measures, even in a country without specific legislation. Implications for Practice Organizational changes, such as staff training and increased family support during admission of episodes of mechanical restraint, can reduce the use of this measure. These measures also give the nursing staff greater responsibility in terms of their role in registering and monitoring the restrictive practice, thus helping to prevent or minimize the use of mechanical restraint.

Effect of the introduction of immediate judge's decisions in 2018 on the use of coercive measures in psychiatric hospitals in Germany: a population-based study

Background

On 23 July 2018, the German Constitutional Court decided that mechanical restraint in psychiatric patients lasting longer than 30 minutes requires a judge's immediate decision. On the same day, the German Association for Psychiatry and Psychotherapy published its guideline on the prevention of coercion and violence. The registry for coercive measures in the federal state of Baden-Wuerttemberg, available since 2015 and comprising all 32 hospitals licensed to admit involuntary patients, has made it possible to evaluate the effect of the legal change, considered the strongest intervention ever in Germany to reduce coercion.

Methods

We analysed the mean percentage of patients subjected to coercive measures and the mean cumulative duration of these interventions in ICD-10 diagnostic groups in psychiatric hospitals from 2017 compared to 2019 among a total of 233,0273 admissions.

Findings

The percentage of patients subjected to any kind of freedom-restricting coercion decreased from 6·6% in 2017 to 5·8% in 2019 (p = 0·000). Accordingly, the percentage of patients subjected to mechanical restraint decreased from 4·8% to 3·6% in 2019 (p = 0·000). At the same time, the percentage of patients subjected to seclusion increased from 2·9% to 3·3% (p = 0·000). The median cumulated duration of restraint and seclusion per affected case decreased from 12·5 to 11·9 hrs (p = 0·001).

Interpretation

There is clear evidence that a strong legal intervention was effective in reducing the use of coercive measures under routine conditions.

Funding

The registry is funded by the Ministry of Social Welfare and Integration.

Determinants of mechanical restraint in an acute psychiatric care unit

BACKGROUND

Despite numerous attempts to reduce the use of mechanical restraint (MR), this technique continues to be widely applied in many acute psychiatric care settings. In order to reduce MR, a better understanding of the variables associated with its use and duration in different clinical environments is essential.

AIM

To determine the proportion of patients subjected to MR and the duration thereof in two acute care psychiatric units; and to identify the variables associated with the use and duration of MR.

METHODS

Descriptive study of all patients admitted to the acute psychiatric units at the Parc de Salut Mar (Barcelona, Spain) in the year 2018. The number and percentage of patients subjected to MR, as well as the duration of each episode were assessed. The following data were also registered: sociodemographic characteristics, psychiatric diagnosis, and presence of cultural and/or language barriers. Multivariate analyses were performed to assess determinants of MR and its duration.

RESULTS

Of the 464 patients, 119 (25.6%) required MR, with a median of 16.4 h per MR. Two factors - a diagnosis of psychotic disorder [Odds ratios (OR) = 0.22; 95%CI: 0.06-0.62; P = 0.005] and the presence of a language barrier (OR = 2.13; 95%CI: 1.2-3.7; P = 0.007) - were associated with a significantly higher risk of MR. Male sex was associated with a longer duration of MR (B = -19.03; 95%CI: -38.06-0.008; P = 0.05).

CONCLUSION

The presence of a language barrier and a psychotic disorder diagnosis are associated with a significantly higher risk of MR. Furthermore, male sex is associated with a longer duration of MR. Individualized restraint protocols that include the required tools are necessary to ultimately limit the use of mechanical restraint.

Aggression on the psychiatric ward: Prevalence and risk factors. A systematic review of the literature

INTRODUCTION

On psychiatric wards, aggressive behaviour displayed by patients is common and problematic. Understanding factors associated with the development of aggression offers possibilities for prevention and targeted interventions. This review discusses factors that contribute to the development of aggression on psychiatric wards.

METHOD

In Pubmed and Embase, a search was performed aimed at: prevalence data, ward characteristics, patient and staff factors that are associated with aggressive behaviour and from this search 146 studies were included.

RESULTS

The prevalence of aggressive behaviour on psychiatric wards varied (8-76%). Explanatory factors of aggressive behaviour were subdivided into patient, staff and ward factors. Patient risk factors were diagnosis of psychotic disorder or bipolar disorder, substance abuse, a history of aggression, younger age. Staff risk factors included male gender, unqualified or temporary staff, job strain, dissatisfaction with the job or management, burn-out and quality of the interaction between patients and staff. Staff protective factors were a good functioning team, good leadership and being involved in treatment decisions. Significant ward risk factors were a higher bed occupancy, busy places on the ward, walking rounds, an unsafe environment, a restrictive environment, lack of structure in the day, smoking and lack of privacy.

CONCLUSION

Despite a lack of prospective quantitative data, results did show that aggression arises from a combination of patient factors, staff factors and ward factors. Patient factors were studied most often, however, besides treatment, offering the least possibilities in prevention of aggression development. Future studies should focus more on the earlier stages of aggression such as agitation and on factors that are better suited for preventing aggression such as ward and staff factors. Management and clinicians could adapt staffing and ward in line with these results.

"Can mental health nurses working in acute mental health units really be trauma-informed?" An integrative review of the literature

WHAT IS KNOWN ON THE SUBJECT?: The lifetime prevalence of trauma for consumers of mental health services is high. Both nurses and consumers of mental health services experience trauma and re-traumatization in mental health units. TIC is a model of care or approach increasingly used in mental health units to guide nursing actions to minimize trauma and re-traumatization for those working and accessing mental health services. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Overall, there is poor quality of studies exploring TIC in acute mental health units from the perspective of the MHN. Acute mental health units have competing organizational demands that can often be a source of conflict for nurses providing TIC. To be trauma-informed, a critical examination of the dynamic and unique system-related processes in mental health units is required. TIC literature reveals that nurses are seeking to develop the basic skills expected to be gained in earlier preparatory education to respond therapeutically to consumers. Not all MHNs agree that TIC is necessarily a new or useful model to inform their practice. Trauma and re-traumatization experienced by MHNs can be a source of conflict for TIC in the mental health unit environment. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The broader environmental and organizational demands placed on nurses can create professional and moral conflict for providing TIC. TIC should acknowledge trauma and re-traumatization experienced by MHNs in the acute mental health units.

ABSTRACT

INTRODUCTION: Trauma-informed care (TIC) is an approach that mental health inpatient units are increasingly adopting, with mental health nurses (MHNs) being the largest occupational group working this area.

AIM

To critically examine the literature on TIC in mental health inpatient units from a MHN perspective.

METHODS

Primary studies examining TIC in mental health inpatient units from a MHN perspective were examined in CINAHL, Medline and PsycINFO database including the reference lists of primary sources. A total of n = 10 studies met the inclusion criteria with four themes identified.

DISCUSSION

There is a paucity of quality research available on TIC to guide MHNs employed in mental health inpatient units. The review has highlighted that MHN practice is influenced by the medical model ideology and competing organizational demands that can at least partially negate the effective provision of TIC.

IMPLICATIONS FOR PRACTICE

For purposeful application of TIC, the parallel and often unconscious organizational processes that exist for MHNs working in mental health units must too be examined.

RELEVANCE STATEMENT

The review invites an opportunity for important reflections by MHNs employed in mental health units. TIC may help restore MHN practice to the interpersonal tenants the profession is best distinguished by.

A Bayesian network model to identify the associations between the use of seclusion in psychiatric care and nursing managers' attitudes towards containment methods

WHAT IS KNOWN ON THE SUBJECT

Seclusion is used frequently in psychiatric care, despite its potential adverse effects. Several programmes aiming to reduce the use of seclusion identify leadership and management as key strategies-however, studies concerning leaders and managers are missing.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

Nursing managers' negative attitudes towards seclusion are associated with less use of the measure, and nursing managers' higher age is associated with increased use of seclusion.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

Nursing managers should be encouraged to guide their staff to reduce the use of seclusion. The negative influences of seclusion and the potential of alternative measures should be highlighted in the education and training of psychiatric nursing managers.

ABSTRACT

Introduction The use of seclusion in psychiatric care should be reduced. The relationship between nursing management or nursing managers' attitudes and the use of seclusion has not been investigated. Aim To describe the associations between the use of seclusion and psychiatric nursing managers' attitudes to containment methods. Method Register data concerning the use of seclusion in Finnish psychiatric care in 2017 were collected. The Attitudes to Containment Measures Questionnaire was used to illustrate psychiatric nursing managers' attitudes to containment methods. An Augmented Naive Bayes analysis was used to investigate the relationships of the use of seclusion and attitudes. Results Nursing managers' age and their attitudes towards containment methods were related to the use of seclusion. Especially nursing managers' negative perceptions of seclusion were associated with less use of seclusion, and seclusion was used more often on wards with nursing managers who were older than the average. Conclusion Nursing managers' negative attitudes towards seclusion have a potential impact on the use of seclusion, which might even result in a reduction in its use in psychiatric inpatient setting. Implications for practice The results suggest that nursing managers should be encouraged to guide their staff to decrease the use of seclusion.

A New Perspective on Human Rights in the Use of Physical Restraint on Psychiatric Patients-Based on Merleau-Ponty's Phenomenology of the Body

(1) Background: Physical restraint in psychiatric settings must be determined by health care professionals for ensuring their patients’ safety. However, when a patient cannot participate in the process of deciding what occurs in their own body, can they even be considered as a personal self who lives in and experiences the lifeworld? The purpose of this study is to review the existential capability of the body from Merleau-Ponty’s phenomenology to explore ways of promoting human rights in physical restraint. (2) Methods: A philosophical reflection was contemplated regarding notions of the body’s phenomenology. (3) Results: Merleau-Ponty’s body phenomenology can explain bodily phenomena as a source of the personal subject, who perceives and acts in the world, and not as a body alienated from the subject in health and illness. Patients, when they are physically restrained, cannot be the self as a subject because their body loses its subjecthood. They are entirely objectified, becoming objects of diagnosis, protection, and control, according to the treatment principles of health care professionals. (4) Conclusions: The foundation of human rights, human being’s dignity lies in the health professionals’ genuine understanding and response to the existential crisis of the patient’s body in relation to its surrounding environment.