Long-Term Impact of a Tailored Seclusion Reduction Program: Evidence for Change?

[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.

The Forensic High and Intensive Care Monitor: Measurement Properties of a Model Fidelity Scale for Contact-Based Care in Forensic Psychiatry

Forensic High and Intensive Care (FHIC) has recently been developed as a new care model in Dutch forensic psychiatry. FHIC aims to provide contact-based care. To support Dutch forensic care institutions in the implementation of the model, a model fidelity scale was developed called the FHIC monitor. The aim of this study was to assess the inter-rater reliability, content validity, and construct validity of the FHIC monitor. A multi-methods design was used, combining qualitative and quantitative research. To collect data, audits and focus group meetings were organized to score care at individual wards with the monitor and get feedback from auditors and audit receiving teams about the quality of the monitor. In total, fifteen forensic mental healthcare institutions participated. The instrument showed acceptable inter-rater reliability and content validity, and a significant difference between expected high and low scoring institutions, supporting construct validity. The instrument can be used as a valid instrument to measure the level of implementation of the FHIC model on forensic psychiatric wards in the Netherlands.

Non-pharmacological interventions to reduce restrictive practices in adult mental health inpatient settings: the COMPARE systematic mapping review

Objectives

The study aimed to provide a mapping review of non-pharmacological interventions to reduce restrictive practices in adult mental health inpatient settings; classify intervention components using the behaviour change technique taxonomy; explore evidence of behaviour change techniques and interventions; and identify the behaviour change techniques that show most effectiveness and those that require further testing.

Background

Incidents involving violence and aggression occur frequently in adult mental health inpatient settings. They often result in restrictive practices such as restraint and seclusion. These practices carry significant risks, including physical and psychological harm to service users and staff, and costs to the NHS. A number of interventions aim to reduce the use of restrictive practices by using behaviour change techniques to modify practice. Some interventions have been evaluated, but effectiveness research is hampered by limited attention to the specific components. The behaviour change technique taxonomy provides a common language with which to specify intervention content.

Design

Systematic mapping study and analysis.

Data sources

English-language health and social care research databases, and grey literature, including social media. The databases searched included British Nursing Index (BNI), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CCRCT), Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE), EMBASE, Health Technology Assessment (HTA) Database, HTA Canadian and International, Ovid MEDLINE®, NHS Economic Evaluation Database (NHS EED), PsycInfo®and PubMed. Databases were searched from 1999 to 2019.

Review methods

Broad literature search; identification, description and classification of interventions using the behaviour change technique taxonomy; and quality appraisal of reports. Records of interventions to reduce any form of restrictive practice used with adults in mental health services were retrieved and subject to scrutiny of content, to identify interventions; quality appraisal, using the Mixed Methods Appraisal Tool; and data extraction, regarding whether participants were staff or service users, number of participants, study setting, intervention type, procedures and fidelity. The resulting data set for extraction was guided by the Workgroup for Intervention Development and Evaluation Research, Cochrane and theory coding scheme recommendations. The behaviour change technique taxonomy was applied systematically to each identified intervention. Intervention data were examined for overarching patterns, range and frequency. Overall percentages of behaviour change techniques by behaviour change technique cluster were reported. Procedures used within interventions, for example staff training, were described using the behaviour change technique taxonomy.

Results

The final data set comprised 221 records reporting 150 interventions, 109 of which had been evaluated. The most common evaluation approach was a non-randomised design. There were six randomised controlled trials. Behaviour change techniques from 14 out of a possible 16 clusters were detected. Behaviour change techniques found in the interventions were most likely to be those that demonstrated statistically significant effects. The most common intervention target was seclusion and restraint reduction. The most common strategy was staff training. Over two-thirds of the behaviour change techniques mapped onto four clusters, that is ‘goals and planning’, ‘antecedents’, ‘shaping knowledge’ and ‘feedback and monitoring’. The number of behaviour change techniques identified per intervention ranged from 1 to 33 (mean 8 techniques).

Limitations

Many interventions were poorly described and might have contained additional behaviour change techniques that were not detected. The finding that the evidence was weak restricted the study’s scope for examining behaviour change technique effectiveness. The literature search was restricted to English-language records.

Conclusions

Studies on interventions to reduce restrictive practices appear to be diverse and poor. Interventions tend to contain multiple procedures delivered in multiple ways.

Future work

Prior to future commissioning decisions, further research to enhance the evidence base could help address the urgent need for effective strategies. Testing individual procedures, for example, audit and feedback, could ascertain which are the most effective intervention components. Separate testing of individual components could improve understanding of content and delivery.

Study registration

The study is registered as PROSPERO CRD42018086985.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 9, No. 5. See the NIHR Journals Library website for further project information.

The Compulsory Care Act: Early Observations and Expectations of In- or Outpatient Involuntary Treatment

BACKGROUND

On January 1, 2020, the Dutch Compulsory Care Act (WvGGZ) replaced the Special Admissions Act (BOPZ). While the old law only allowed compulsory treatment in hospitals, the new law allows it both inside and outside the hospital. Moreover, the new law prioritizes the patient's own opinion on coercive measures. By following patients' own choices, the Compulsory Care Act is hoped to lead to fewer admission days and less inpatient compulsory treatment in involuntarily admitted patients.

METHODS

We studied the seclusion and enforced-medication events before and after January 1, 2020, using coercive measures monitoring data in a Mental Health Trust. Trends in hours of seclusion and the number of enforced-medication events per month from 2012 to 2019 were compared with 2020. We used generalized linear models to perform time series analysis. Logistic regression analyses and generalized linear models were performed to investigate whether patient compilation determined some of the observed changes in seclusion use or enforced-medication events.

RESULTS

The mean number of hours of seclusion between 2012 and 2019 was 27,124 per year, decreasing from 48,542 in 2012 to 21,133 in 2019 to 3,844 h in 2020. The mean incidence of enforced-medication events between 2012 and 2019 was 167, increasing from 90 in 2012 to 361 in 2019 and then fell to 294 in 2020. In 2020, we observed 3,844 h of seclusion and 294 enforced-medication events. Near to no outpatient coercion was reported, even though it was warranted. The time series analysis showed a significant effect of the year 2020 on seclusion hours (β = -1.867; Exp(β) = 0.155, Wald = 27.22, p = 0.001), but not on enforced-medication events [β = 0.48; Exp(β) = 1.616, Wald = 2.33, p = 0.13].

DISCUSSION

There was a reduction in the number of seclusion hours after the introduction of the Compulsory Care Act. The number of enforced-medication events also increased from a very low baseline, but from 2017 onwards. To see whether these findings are consistent over time, they need to be replicated in the near future.

CONCLUSION

We observed a significant increase in enforced-medication use and a decrease in seclusion hours. The year 2020 predicted seclusion hours, but not enforced-medication events.

Does high and intensive care reduce coercion? Association of HIC model fidelity to seclusion use in the Netherlands

BACKGROUND

A new inpatient care model has been developed in the Netherlands: High and Intensive Care (HIC). The purpose of HIC is to improve quality of inpatient mental healthcare and to reduce coercion.

METHODS

In 2014, audits were held at 32 closed acute admission wards for adult patients throughout the Netherlands. The audits were done by trained auditors, who were professionals of the participating institutes, using the HIC monitor, a model fidelity scale to assess implementation of the HIC model. The HIC model fidelity scale (67 items) encompasses 11 domains including for example team structure, team processes, diagnostics and treatment, and building environment. Data on seclusion and forced medication was collected using the Argus rating scale. The association between HIC monitor scores and the use of seclusion and forced medication was analyzed, corrected for patient characteristics.

RESULTS

Results showed that wards having a relatively high HIC monitor total score, indicating a high level of implementation of the model as compared to wards scoring lower on the monitor, had lower seclusion hours per admission hours (2.58 versus 4.20) and less forced medication events per admission days (0.0162 versus 0.0207). The HIC model fidelity scores explained 27% of the variance in seclusion rates (p < 0.001). Adding patient characteristics to HIC items in the regression model showed an increase of the explained variance to 40%.

CONCLUSIONS

This study showed that higher HIC model fidelity was associated with less seclusion and less forced medication at acute closed psychiatric wards in the Netherlands.

Three Pathways of Seclusion Reduction Programs to Sustainability: Ten Years Follow Up in Psychiatry

From 2004 onwards, above 50 seclusion reduction programs (SRP) were developed, implemented and evaluated in the Netherlands. However, little is known about their sustainability, as to which extent obtained reduction could be maintained. This study monitored three programs over ten years seeking to identify important factors contributing to this. We reviewed documents of three SRPs that received governmental funding to reduce seclusion. Next, we interviewed key figures from each institute, to investigate the SRP documents and their implementation in practice. We monitored the number of seclusion events and the number of seclusion days with the Argus rating scale over ten years in three separate phases: 2008-2010, 2011-2014 and 2015-2017. As we were interested in sustainability after the governmental funding ended in 2012, our focus was on the last phase. Although in different rate, all mental health institutes showed some decline in seclusion events during and immediately after the SRP. After end of funding one institute showed numbers going up and down. The second showed an increase in number of seclusion days. The third institute displayed a sustained and continuous reduction in use of seclusion, even several years after the received funding. This institute was the only one with an ongoing institutional SRP after the governmental funding. To sustain accomplished seclusion reduction, a continuous effort is needed for institutional awareness of the use of seclusion, even after successful implementation of SRPs. If not, successful SRPs implemented in psychiatry will easily relapse in traditional use of seclusion.

Prevalence of the use of chemical restraint in the management of challenging behaviours associated with adult mental health conditions: A meta-synthesis

WHAT IS KNOWN ON THE SUBJECT?: The use of chemical restraint in emergency situations is to control aggression or violence to protect consumers and staff and is to be used as a last resort when all other behavioural control alternatives have been exhausted. Chemical restraint involves the use of medication. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first paper to systematically review the prevalence of the use of chemical restraint. The use of chemical restraint is common across emergency departments and acute psychiatric inpatient units worldwide. Consumers who are restrained are also likely to receive chemical restraint. The studies reviewed demonstrate that there is a need for more standardized data collection so that clearer comparisons can be made between healthcare settings and countries. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Implications of practice include the need to report adverse events post-chemical restraint as these can deleteriously affect a person's physical health. Identification of and staff education about first-line management techniques before chemical restraint is administered are significant to reduce its use. ABSTRACT: Introduction Chemical restraint is used to manage uncontrolled aggression, agitation or violent behaviours of consumers with mental health disorders admitted to acute psychiatric or emergency settings. Aim This systematic review aimed to synthesize the international prevalence of chemical restraint for non-consenting adults. Method PsycINFO, CINAHL, MEDLINE/PubMed and Google Scholar databases were searched for peer-reviewed literature published between January 1996 and July 2018. This paper reports on data extracted from retrospective audits of chemical restraint practice. Results Forty-eight papers were included. The median prevalence of use of any restraint was 21.2% (25th% 8.0 to 75th% 36.3). Median prevalence of people who were chemically restrained, of all people restrained in any manner, was 43.1% (25th% 22.9% to 75th% 70.7%). Of all people admitted to facility(ies), the median prevalence of chemical restraint was 7.4% (25th% 2.7 to 75th% 17.6). There was no statistically significant difference in any prevalence measure considering healthcare setting or country. There was a significant decrease over the review period in the use of any restraint, including chemical restraint. Discussion and implications for practice This is the first known comprehensive meta-view of chemical restraint use worldwide, highlighting the need for standardized data collection to enable comparisons between healthcare settings and countries. Relevance statement There is an international imperative to reduce or eliminate the use of coercive practices, such as physical and chemical restraint, in mental health care. This study provides important information for mental health nursing by synthesizing the international prevalence of chemical restraint for non-consenting adults. This meta-view of the worldwide use of chemical restraint can inform ongoing efforts to reduce its use.

Preventing and reducing 'coercion' in mental health services: an international scoping review of English-language studies

This article discusses initiatives aimed at preventing and reducing 'coercive practices' in mental health and community settings worldwide, including in hospitals in high-income countries, and in family homes and rural communities in low- and middle-income countries. The article provides a scoping review of the current state of English-language empirical research. It identifies several promising opportunities for improving responses that promote support based on individuals' rights, will and preferences. It also points out several gaps in research and practice (including, importantly, a gap in reviews of non-English-language studies). Overall, many studies suggest that efforts to prevent and reduce coercion appear to be effective. However, no jurisdiction appears to have combined the full suite of laws, policies and practices which are available, and which taken together might further the goal of eliminating coercion.

Measures to Avoid Coercion in Psychiatry and Their Efficacy

BACKGROUND

Coercive measures such as seclusion and restraint encroach on the patient's human rights and can have serious adverse effects ranging from emotional trauma to physical injury and even death. At the same time, they may be the only way to avert acute danger for the patient and/or the hospital staff. In this article, we provide an overview of the efficacy of the measures that have been studied to date for the avoidance of coercion in psychiatry.

METHODS

This review is based on publications retrieved by a systematic search in the Medline and Cinahl databases, supplemented by a search in the reference lists of these publications. We provide a narrative synthesis in which we categorize the interventions by content.

RESULTS

Of the 84 studies included in this review, 16 had a control group; 6 of these 16 were randomized controlled trials (RCTs). The interventions were categorized by seven different types of content: organization, staff training, risk assessment, environment, psychotherapy, debriefings, and advance directives. Most interventions in each category were found to be effective in the respective studies. 38 studies investigated complex treatment programs that incorporated elements from more than one category; 37 of these (including one RCT) revealed effective reduction of the frequency of coercion. Two RCTs on the use of rating instruments to assess the risk of aggressive behavior revealed a relative reduction of the number of seclusion measures by 27% and a reduction of the cumulative duration of seclusion by 45%.

CONCLUSION

Complex intervention programs to avoid coercive measures, incorporating elements of more than one of the above categories, seem to be particularly effective. In future, cluster-randomized trials to investigate the individual categories of intervention would be desirable.

International research into 22 years of use of chemical restraint: An evidence overview

BACKGROUND

Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non-consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice.

AIMS

To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995.

METHODS

This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures.

RESULTS

This review identified 311 relevant primary studies (21 RCTs; 46 non-controlled experimental or prospective observational studies; 77 cross-sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross-country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%).

DISCUSSION

A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non-consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non-chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research.

Using interventions to reduce seclusion and mechanical restraint use in adult psychiatric units: an integrative review

The aim of this integrative review was to describe interventions aimed at reducing seclusion and mechanical restraint use in adult psychiatric inpatient units and their possible outcomes. CINAHL, MEDLINE, PsycINFO and Medic databases were searched for studies published between 2008 and 2017. Based on electronic and manual searches, 28 studies were included, and quality appraisal was carried out. Data were analysed using inductive content analysis. Interventions to proactively address seclusion were environmental interventions, staff training, treatment planning, use of information and risk assessment. Interventions to respond to seclusion risk were patient involvement, family involvement, meaningful activities, sensory modulation and interventions to manage patient agitation. Interventions to proactively address mechanical restraint were mechanical restraint regulations, a therapeutic atmosphere, staff training, treatment planning and review of mechanical restraint risks. Interventions to respond to mechanical restraint risks included patient involvement, therapeutic activities, sensory modulation and interventions to manage agitation. Outcomes related to both seclusion and mechanical restraint reduction interventions were varied, with several interventions resulting in both reduced and unchanged or increased use. Outcomes were also reported for combinations of several interventions in the form of reduction programmes for both seclusion and mechanical restraint. Much of the research focused on implementing several interventions simultaneously, making it difficult to distinguish outcomes. Further research is suggested on the effectiveness of interventions and the contexts they are implemented in.

Text Analysis of Electronic Medical Records to Predict Seclusion in Psychiatric Wards: Proof of Concept

Aim: With the introduction of "Electronic Medical Record" (EMR) a wealth of digital data has become available. This provides a unique opportunity for exploring precedents for seclusion. This study explored the feasibility of text mining analysis in the EMR to eventually help reduce the use of seclusion in psychiatry. Methods: The texts in notes and reports of the EMR during 5 years on an acute and non-acute psychiatric ward were analyzed using a text mining application. A period of 14 days was selected before seclusion or for non-secluded patients, before discharge. The resulting concepts were analyzed using chi-square tests to assess which concepts had a significant higher or lower frequency than expected in the "seclusion" and "non-seclusion" categories. Results: Text mining led to an overview of 1,500 meaningful concepts. In the 14 day period prior to the event, 115 of these concepts had a significantly higher frequency in the seclusion category and 49 in the non-seclusion category. Analysis of the concepts from days 14 to 7 resulted in 54 concepts with a significantly higher frequency in the seclusion-category and 14 in the non-seclusion category. Conclusions: The resulting significant concepts are comparable to reasons for seclusion in literature. These results are "proof of concept". Analyzing text of reports in the EMR seems therefore promising as contribution to tools available for the prediction of seclusion. The next step is to build, train and test a model, before text mining can be part of an evidence-based clinical decision making tool.