Listening to the Patient Perspective: Psychiatric Inpatients' Attitudes Towards Physical Restraint

Managing Aggressive Behaviour in Healthcare: Balancing of Patients and Staff Interests

The incidence of aggression within healthcare environments has exhibited a discernible rise. As a response, restrictive measures, including restraints, are enforced. Due to the safety and ethical concerns associated with using restraint, de-escalation measures are regarded as the most efficient course of action. The paper posits that it is critical to identify the causes of aggression before employing restraint through a multidisciplinary risk assessment. In addition, the reasonableness and proportionality of administering restraint must be carefully measured. The significance of cultivating a therapeutic and compassionate environment is emphasised. The paper will exclusively examine physical restraint as a form of restriction intervention.

The restraint chair: A qualitative study of the patient experience

Despite initiatives to eliminate restraint from acute psychiatric care, there remain times when violent episodes threaten the safety of patients and/or staff. The restraint chair may be used in these moments and provide an alternative to four-point restraint. The purpose of this study was to examine the patient experience of the restraint chair. Patients who had an episode of restraint in the restraint chair during their hospital stay were interviewed about the experience. Participants described the experience as "unpleasant," with the majority preferring the restraint chair to other methods of restraint they had experienced. Participants indicated they could "understand" why the restraint had occurred and felt staff were "helpful" and "create safety." Finally, participants stated the hospital experience was "positive." Although the goal remains to eliminate restraint, psychiatric settings may want to consider the restraint chair as an alternative to four-point restraint for situations requiring mechanical restraint. Nurses' presence and communication with patients during the restraint process is important to the patient experience. More research is needed to verify these results.

Development of a Pediatric Behavioral Early Warning Scale (Pedi-BEWS) for Children

Background and Purpose: The prevention of aggressive behavior in child and adolescent inpatient settings is essential. However, it can be difficult to prompt a quick appropriate intervention without an early warning scale for the prevention and management of behavioral emergencies in a psychiatric inpatient adolescent unit. Behavioral emergencies often result in restraint/seclusion and/or administration of psychotropic medications. The objectives are to develop and evaluate the Pediatric Behavioral Early Warning Scale (Pedi-BEWS) as a screening tool to prompt quick appropriate interventions and to decrease incidents of restraint/seclusion and/or administration of psychotropic medications. Methods: A two-phase methodological design was applied. A total of 447 inpatients and 21 nurses were used to test internal consistency reliability and validity. Results: Receiver operating characteristic curve areas for the developed instrument were calculated to be 0.890 (cognition), 0.959 (affect), and 0.951 (behavior). The overall Pedi-BEWS indicated high reliability (Cronbach's alpha = .98). Conclusions: The Pedi-BEWS shows high internal consistency and validity. The use of the newly developed tool may reduce or eliminate episodes of seclusion and restraint for pediatric patients with a behavioral problem. In addition, the tool has the potential to enhance psychiatric nurses' assessment skills and competencies. The use of the newly developed Pedi-BEWS can promote an appropriate and timely nursing assessment and intervention before the deterioration in psychiatric nursing practice.

Predictive care: a protocol for a computational ethnographic approach to building fair models of inpatient violence in emergency psychiatry

INTRODUCTION

Managing violence or aggression is an ongoing challenge in emergency psychiatry. Many patients identified as being at risk do not go on to become violent or aggressive. Efforts to automate the assessment of risk involve training machine learning (ML) models on data from electronic health records (EHRs) to predict these behaviours. However, no studies to date have examined which patient groups may be over-represented in false positive predictions, despite evidence of social and clinical biases that may lead to higher perceptions of risk in patients defined by intersecting features (eg, race, gender). Because risk assessment can impact psychiatric care (eg, via coercive measures, such as restraints), it is unclear which patients might be underserved or harmed by the application of ML.

METHODS AND ANALYSIS

We pilot a computational ethnography to study how the integration of ML into risk assessment might impact acute psychiatric care, with a focus on how EHR data is compiled and used to predict a risk of violence or aggression. Our objectives include: (1) evaluating an ML model trained on psychiatric EHRs to predict violent or aggressive incidents for intersectional bias; and (2) completing participant observation and qualitative interviews in an emergency psychiatric setting to explore how social, clinical and structural biases are encoded in the training data. Our overall aim is to study the impact of ML applications in acute psychiatry on marginalised and underserved patient groups.

ETHICS AND DISSEMINATION

The project was approved by the research ethics board at The Centre for Addiction and Mental Health (053/2021). Study findings will be presented in peer-reviewed journals, conferences and shared with service users and providers.

Experiences and perceptions of coercive practices in mental health care among service users in Nigeria: a qualitative study

BACKGROUND

People with mental health problems are more vulnerable to a broad range of coercive practices and human rights abuses. There is a global campaign to eliminate, or at the very least decrease, the use of coercion in mental health care. The use of coercion in psychiatric hospitals in developing countries is poorly documented. The primary aim of this study was to explore service users' perceptions and experiences of coercion in psychiatric hospitals in Nigeria.

METHODS

Four focus group discussions were carried out among 30 service users on admission in two major psychiatric hospitals in Nigeria. The audio recordings were transcribed verbatim and then analyzed thematically with the aid of MAXQDA software.

RESULTS

The Focus group participants included 19 males and 11 females with a mean age of 34.67 ± 9.54. Schizophrenia was the most common diagnosis (40%, n = 12) and had a secondary school education (60%, n = 18). The focus group participants perceived coercion to be a necessary evil in severe cases but anti-therapeutic to their own recovery, an extension of stigma and a vicious cycle of abuse. The experience of involuntary admission revolved mainly around deception, maltreatment, and disdain. Participants in both study sites narrated experiences of being flogged for refusing medication. Mechanical restraint with chains was a common experience for reasons including refusing medications, to prevent absconding and in other cases, punitively. The use of chains was viewed by participants as dehumanizing and excruciatingly painful.

CONCLUSION

The experiences of coercion by participants in this study confirm that human rights violations occur in large psychiatric hospitals and underscore the need for mental health services reform. The use of coercion in this context reflects agelong underinvestment in the mental health care system in the country and obsolete mental health legislation that does not protect the rights of people with mental health problems. The study findings highlight an urgent need to address issues of human rights violations in psychiatric hospitals in the country.

Patient Experience of Physical Restraint in the Acute Setting: A Systematic Review of the Qualitative Research Evidence

The use of physical restraint is a contentious practice in the acute mental health setting. There are a plethora of guidelines surrounding the safe use of restraint. However, there is a scarcity of literature dedicated specifically from the perspective of the patient. The existing literature suggests that there are serious physical and psychological implications associated with the use of physical restraint for both mental health patients and nurses alike. The debate surrounding this practice has been intensified by the compelling evidence suggesting that the application of restraint is not compatible with the values of recovery in mental health care. To influence clinical practice that governs the use of restraint, it is essential to explore patient experiences of its use. Therefore, this review aims to explore patient experiences of physical restraint in the acute setting. PubMed, CINAHL and PsycINFO were systematically searched using keywords; "physical restraint" and "patient experience" and "acute setting". The search yielded n = 482 papers in total. Following the application of rigorous inclusion and exclusion criteria and data extraction, a total of n = 9 papers were considered suitable for the systematic review. Quality was assessed using the MMAT instrument. Following analysis, three themes were identified: 'the bio-psychosocial impact of restraint on patients', 'the impact of restraint on the therapeutic relationship' and 'patient needs concerning the use of restraint'. Future research opportunities have been identified that will add to the body of evidence in developing appropriate health interventions and supports for this population.

'You get this conflict between you as a person and you in your role…that changes you': A thematic analysis of how inpatient psychiatric healthcare staff in the UK experience restraint, seclusion, and other restrictive practices

A high proportion of psychiatric inpatients experience Restrictive Practice (RP) during admission. Numerous reports have highlighted adverse effects on patients and staff. However, qualitative research focussed on experience, impact, and coping mechanisms of healthcare staff in the UK is limited. Therefore, this study explored psychiatric healthcare staff experience of RP on inpatient wards in the UK. Eight semi-structured, audio-recorded interviews, of ~60 min, were conducted via telephone/Skype and transcribed verbatim. A critical realist epistemology was used to thematically analyse data. Three themes were identified: the coexistence of accountability, power and subjection; impacts on the individual and professional relationships, and coping with difficult experiences and emotions. Restrictive practice can negatively affect staff experience, working relationships, and wellbeing. Opportunities for support could mediate adverse effects. Future research could further explore coping mechanisms and organizational factors contributing to negative staff experiences.

The effect of empathy skills of psychiatric nurses on their attitudes and practices towards the use of physical restraint

PURPOSE

The aim of this study was to evaluate the effect of empathy skills of psychiatric nurses on their attitudes and practices towards the use of physical restraint.

DESIGN AND METHODS

This cross-sectional, correlational, descriptive study included 100 nurses (88.49% of the population). Data were collected using a sociodemographic characteristics form, the empathy skills scale (ESS) form B, and the knowledge, attitudes, and practices of staff towards physical restraints questionnaire (KAPS-PR) were used.

FINDINGS

The total mean ESS score was found to be 152.34 ± 24.44, indicating moderate empathy skills. Mean KAPS-PR scores were 29.54 ± 4.43 for the attitude scale and 33.94 ± 3.26 for the practice scale, indicating appropriate attitudes and ideal practices related to physical restraint, respectively. ESS score was significantly higher among nurses with higher educational levels (p = .001) and weakly correlated with KAPS-PR attitude score (r = .25; p < .05).

IMPLICATIONS FOR PRACTICE

Improving the empathy skills of psychiatric nurses could improve their attitudes towards physical restraint, thereby reducing its use.

Decreasing the Use of Restraints on Children Admitted for Behavioral Health Conditions

OBJECTIVES

Pediatric behavioral health admissions to children's hospitals for disposition planning are steadily increasing. These children may exhibit violent behaviors, which can escalate to application of physical limb restraints for safety. Using quality improvement methodology, we sought to decrease physical restraint use on children admitted to our children's hospital for behavioral health conditions from a baseline mean of 2.6% of behavioral health patient days to <1%.

METHODS

We included all children ≥3 years of age admitted to our hospital medicine service with a primary behavioral health diagnosis from July 1, 2016, to February 1, 2020. A multidisciplinary team, formed in July 2018, tested interventions based on key drivers targeted toward our aim. The primary outcome measure was the percent of behavioral health patient days on which physical restraints were ordered. The balancing measure was the percent of patient days with a staff injury event. Statistical process control charts were used to view and analyze data.

RESULTS

Our cohort included 3962 consecutive behavioral health patient encounters, encompassing a total of 9758 patient days. A 2-year baseline revealed physical restraint orders placed on 2.6% of behavioral health patient days, which was decreased to 0.9% after interventions and has been sustained over 19 months without any change in staff injuries.

CONCLUSIONS

Team-based quality improvement methodology was associated with a sustained reduction in physical restraint use on children admitted for behavioral health conditions to our children's hospital. These results indicate that physical restraint use can be safely reduced in children's hospitals.

Attitude and practice toward physical restraint among psychiatric nurses in Guangdong, China: a cross-sectional survey†

Objective

To explore the correlation between nurses’ attitude and practice toward physical restraint (PR) in psychiatric settings and identify the factors that influence the use of PR.

Methods

A cross-sectional survey was conducted. A self-designed questionnaire containing a PR scale was used to assess the attitude and practice of registered psychiatric nurses in Guangdong, China, from November 1, 2018 to December 31, 2018. Descriptive statistics, the Mann–Whitney U test, the Kruskal–Wallis test, and ordinal regression analysis were used to analyze the data.

Results

The response rate was 74.6%. The nurses’ responses showed neutral attitude and a moderate level of practice regarding the use of PR. Factors such as age, gender, marital status, professional position, nightshift, and the frequency of training programs on PR showed a significant association with nurses’ attitude and practice concerning PR (P < 0.05). In addition to these factors, this study found that the practice of PR was associated with nurses’ attitude toward it (P < 0.05). Our results showed that nurses with a largely negative attitude toward PR were more likely to use it (OR = 1.91, P < 0.001).

Conclusions

Clinically, psychiatric nurses with negative attitude are more likely to practice PR. Training and education programs are highly recommended for nursing managers to change the nursing staff’s attitude, since their attitude may have an impact on the PR what they practice.

Prevention and management of aggressive behaviour in patients at psychiatric hospitals: a document analysis of clinical practice guidelines in Hong Kong

Patient aggressive behaviour remains a significant public health concern worldwide. The use of restraint and seclusion remains a last resort but not an uncommon practice in clinical psychiatry in the management of aggressive events. There seems to be a paucity of evidenced-based research examining the policy framework guiding the use of restraint and seclusion in Asia contexts. The purpose of this study was to conduct an analysis on the guidelines in psychiatric hospitals in Hong Kong, and to explore the extent to which these guidelines were aligned with the international clinical guidelines for the prevention and management of patient aggression in psychiatry. A descriptive document analysis was used to analyse the guidelines from four psychiatric hospitals in Hong Kong in comparison with the NICE (National Institute of Health and Care Excellence UK) guidelines. Data were collected from December 2017 to June 2018. A total of 91 written documents were retrieved. Preventing violence and aggression has the highest level of agreement (31%,) while the use of restrictive interventions has the lowest level of agreement (12%). The sub-recommendation with most in line with the NICE guidelines were restrictive interventions, de-escalation, and improving service users' experiences. However, for example, staff training, working with police, and reduced use of restrictive interventions seemed to have no agreement with the NICE guidelines. Variation exists between the Asian (Hong Kong) local policy framework/guidelines and the European (UK) national policy framework. There are also large discrepancies in the written guidelines on patient aggressive behaviour when comparing local policy frameworks, cluster-based documents, and departmental practices.

What are adult psychiatric inpatients' experience of seclusion: A systematic review of qualitative studies

WHAT IS KNOWN ON THE SUBJECT?: Seclusion involves isolating a patient in a room away from other patients in order to contain aggressive behaviour, and it is used in psychiatric hospitals. Research has found that seclusion is often viewed by patients as negative; however, there is limited in-depth understanding of the deeply personal experience. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This systematic review found that the published research may have flaws with the quality of analysis, mainly due to limited researcher reflexivity. The review of qualitative research revealed that during seclusion, patients feel vulnerable, neglected and abused, disconnected from the experience and that it is dangerous to their mental health. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: For clinicians facilitating the seclusion process to use their therapeutic skills to provide patients with a sense of being cared for. For clinical supervision to allow space to explore interpersonal dynamics during seclusion in order to enhance therapeutic staff-patient interaction. Abstract Introduction There is limited understanding of patients' seclusion experience. A 2013 systematic review provides some insight; however, more knowledge is required in order to improve patient care. This is a systematic review of qualitative research into the patient experience of seclusion. The qualitative focus enables the phenomena to be the central focus. Question "What are adult psychiatric inpatients' experience of seclusion?" and "What is the quality of the applicable research?" Method Electronic searches for qualitative research published between 2006 and 2017 were undertaken. Data were excluded if it was not explicitly related to seclusion. Research was appraised using three standardized appraisal criterion. Themes were generated through thematic synthesis. Results Eight papers met inclusion criteria; four had been translated into English. Four themes were identified: "feeling vulnerable," "feeling neglected and abused," "disconnecting" and "seclusion is dangerous to mental health." Participants felt vulnerable and without control. They experienced staff and room as neglectful and abusive. Participants mentally disconnected. The experience threatened participants' mental health. Discussion Participants' experience is an amalgamation of interpersonal experience and the environment. Disconnecting may be a coping strategy. Implications for practice The findings have implications for seclusion practice, staff training and clinical supervision. Specific attention needs to be paid to the staff-patient interaction.