A study of the official records of seclusion

"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.

East London Modified-Broset as Decision-Making Tool to Predict Seclusion in Psychiatric Intensive Care Units

Seclusion is a last resort intervention for management of aggressive behavior in psychiatric settings. There is no current objective and practical decision-making instrument for seclusion use on psychiatric wards. Our aim was to test the predictive and discriminatory characteristics of the East London Modified-Broset (ELMB), to delineate its decision-making profile for seclusion of adult psychiatric patients, and second to benchmark it against the psychometric properties of the Broset Violence Checklist (BVC). ELMB, an 8-item modified version of the 6-item BVC, was retrospectively employed to evaluate the seclusion decision-making process on two Psychiatric Intensive Care Units (patients n = 201; incidents n = 2,187). Data analyses were carried out using multivariate regression and Receiver Operating Characteristic (ROC) curves. Predictors of seclusion were: physical violence toward staff/patients OR = 24.2; non-compliance with PRN (pro re nata) medications OR = 9.8; and damage to hospital property OR = 2.9. ROC analyses indicated that ELMB was significantly more accurate that BVC, with higher sensitivity, specificity, and positive likelihood ratio. Results were similar across gender. The ELMB is a sensitive and specific instrument that can be used to guide the decision-making process when implementing seclusion.

[Use of restraint in psychiatry: Feelings of caregivers and ethical perspectives]

INTRODUCTION

The return of restraint in psychiatry raises many ethical issues for caregivers. However their experience is little explored in literature.

OBJECTIVES

Our objective was to study the feelings of caregivers facing restraint with regard to an ethical perspective and to identify areas for improvement.

METHOD

Between November 2011 and February 2012 a descriptive cross-sectional epidemiological study was performed in two psychiatric emergency services and two closed units in which doctors and nurses were individually interviewed using semi-structured questionnaires. Five topics were explored: indications and contexts, impact on the patient, caregiver-patient relationship, perspective on the practice and feelings of caregivers on which we insist particularly. Results were presented in tables with percentages and possibly diagrams. The notable responses of caregivers were also cited.

RESULTS

Twenty nurses and nine psychiatrists, mostly female, were recruited. They all had participated in experiments of restraint. The self-aggressiveness, the aggressiveness against other persons and agitation were the most frequent indications. In the patients, caregivers identified misunderstanding (79.3%) and anger (75.9%). The majority of nurses (75%) felt that there was an improvement in the caregiver-patient relationship after the episode of restraint compared to what it had been in the moments preceding this measure. The emotional experience of caregivers was rich, intense and predominantly negative type of frustration (35% of nurses; 66.7% of doctors), anger (30 and 33.3%) and lack of feeling (35 and 44.4%). The feelings of doctors and nurses were not completely similar. For caregivers it was "a difficult but necessary experience" (82.75%), "an act of care and safety" (68.9%). All psychiatrists and almost half of the nurses (45%) said they did not feel the same when they used seclusion. In their opinion, seclusion entailed a less painful experience because of its therapeutic properties. More than half of the caregivers thought that there were alternatives to restraint: the strengthening of containing function in the hours before the use of restraint; the use of seclusion at the time of the decision to restrain. They identified contexts (80%) encouraging the use of restraints, not only related to the patient, the lack of resources but also institutional contexts, in particular conflicts or divisions in the health care team.

DISCUSSION

The misunderstanding of the patient led us to wonder about the quality of the information he/she received: it was sometimes too formal and did not take into account the uniqueness of the patient. The frustration of caregivers could concern the lack of resources but also be directed towards a patient or caregiver. In addition, there were often cleavages between doctors and nurses that stemmed from a misunderstanding, also with rivalries and power struggles. From the literature and caregivers' reflections we identified three prospects to reduce the use of restraint and modify feelings of caregivers: 1) develop better crisis management upstream through increasing resources and improving training; 2) promote patients support in using ethical principles of autonomy and beneficence by showing them solicitude, inviting them to tell themselves and helping them to regain their own experience; 3) develop an afterthought in setting up institutional reflection time by restoring a central role in clinical team meetings in psychiatry, possibly supplemented by supervision, but also through regional ethical spaces.

CONCLUSION

In our investigation, we found that caregivers had a predominantly negative experience with frustration, anger and a lack of feeling. Among caregivers we also identified awareness of ethical issues that may be for the first time for a change.

Mechanical restraint in adolescent psychiatry: a Finnish Register study

BACKGROUND

Little is known of the use of mechanical restraint in adolescent psychiatry.

AIMS

To investigate the frequency and features of mechanical restraint in the field of Finnish adolescent psychiatry.

METHODS

The data were collected in the metropolitan area of Helsinki, Finland, with seven closed and eight open wards for Finnish-speaking 13-17-year-old adolescents. The official restraint reports and the hospital files of the restraint patients from January 2009 to December 2009 were collected and analyzed.

RESULTS

Among adolescents hospitalized in closed wards, the 1-year prevalence of mechanical restraint was 9.5%. Among all hospitalized adolescents, the prevalence was 6.9%. The number of mechanically restrained individuals per 100,000 13 to 17-year -old Finnish-speaking inhabitants was 57.1. The median duration of the restraint episode was 4 h and 50 min, but almost half of the mechanical restraint episodes lasted 8 h or more. A quarter of restraint episodes were not based on reasons mentioned in the Finnish Mental Health Act. The most frequent diagnostic categories of mechanically restrained adolescents were mood disorders followed by schizophrenia-related as well as behavioral and emotional disorders. Suicidality preceded 40% and violence 61% of restraint episodes. Boys were restrained during the first days of hospital treatment significantly more often than were girls, whereas one in four girls experienced her first episode of restraint after 1 month of hospitalization.

CONCLUSIONS

Reducing the number and shortening the length of mechanical restraint episodes requires education of staff as well as projects focusing on reducing coercion. The clinical guidelines must be followed at grassroots level.

Exploring patterns of seclusion use in Australian mental health services

Seclusion has remained a common practice in mental health services. In Australia, recent mental health policy has reflected a desire to reduce (and, if possible, eliminate) the use of seclusion. The collection and analysis of data on the use of seclusion have been identified as an important component of the success of reduction initiatives. A cross-sectional design was used in the collection of inpatient unit data on seclusions that occurred in 11 mental health services in Australia over a 6-month period. During this time, there were 4,337 episodes of care. One or more seclusions occurred in 6.8% of episodes of care, with consumers being secluded, on average, 2.32 times and with 44% of them having been secluded more than once. The average length of the seclusions was 2 hours 52 minutes, with 51.4% of seclusions being less than 2 hours. These rates were lower than those reported in previous research studies. The practice of seclusion occurred more commonly on the first 2 days following admission, on weekdays than weekends, and between the hours of 9:00 a.m. and midnight. An understanding of seclusion data can provide fundamental information from which strategies to reduce seclusion can be developed.

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

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

From numbers to understanding: the impact of demographic factors on seclusion rates

The reduction and, where possible, elimination of seclusion has been recognized as a national safety priority for mental health services in Australia, with significant attention devoted to strategies to achieve this goal. The aim of this study was to compare specific demographic characteristics between consumers who have been secluded to those who have not. Patient data (n = 3244) collected by 11 mental health services across Australia for six months over a 12 month period were analysed using demographic statistics. A comparison was undertaken between those who were secluded one or more times (n = 271) and those who were not secluded (n = 2973). Differences were measured with the use of independent samples t-tests and chi-square statistics. Age, gender, diagnosis, indigenous status and Health of the National Outcomes Scores (HoNOS) were found to be significant factors in relation to seclusion. Men, younger people, and indigenous people were found to be more likely to be secluded. In addition, consumers who scored higher on the behaviour,impairment and social subscales of HoNOS were more likely to be secluded. Comparative analysis of demographic characteristics of secluded and non-secluded patients can provide vital information for consideration when planning and evaluating seclusion reduction strategies.

The reasons for using restraint and seclusion in psychiatric inpatient care: A nationwide 15-year study

BACKGROUND

The containment or the prevention of actual violence is the primary justification for the use of restraint and seclusion in psychiatry. The aim of the present study was to determine the grounds for using restraint and seclusion in clinical practice in Finland, and whether these reasons have changed over a 15-year period as a result of legislative changes.

METHOD

A structured postal survey concerning the reasons for restraint and seclusion was completed in all the Finnish psychiatric hospitals during a predetermined week in 1990, 1991, 1994, 1998 and 2004. The duration of the episode as well as demographic and clinical information on the restrained and secluded patient were also reported.

RESULTS

Agitation/disorientation was the most frequent reason for the use of restraint and seclusion. The duration of the restraint and seclusion episodes was not determined by the reason for using these measures. Some differences in the reasons were found among subgroups of patients.

CONCLUSION

Clinical practice deviates from the theoretical and legal grounds established for restraint and seclusion, and is too open to subjective assessment and interpretations.

Does seclusion have a role to play in modern mental health nursing?

The seclusion of patients with mental health problems is a controversial and emotive subject, and is a practice that was condemned by the Ashworth Inquiry (Department of Health (DoH), 1992). Despite this condemnation, it is still widely practised today. Opinions on the practice of seclusion vary greatly. Consequently, there is a need to review the theoretical and empirical literature regarding the use of seclusion in order to gain an understanding of the current state of the knowledge base in this substantive and controversial area. This article systematically reviews research published between 1994 and 1999 and discusses the findings under three headings: staff/patient attitudes to seclusion; the alternatives to seclusion; and the efficacy of seclusion. The reviewed material shows that seclusion is seen as a legitimate intervention by some hospital staff, but is "dreaded" by mental health patients. What is also evident is that seclusion is largely believed to be effective and that no true alternatives to its use exist. However, there appears to be no formal means of determining what constitutes an effective intervention in the management of violent incidents. Implications for practice and areas for future study are also discussed.

The expression and comparison of ward incident rates

The expression of ward incident rates in past research has been unclear and disorganized, resulting in incomparability of information between studies and a lack of precision. Five methods of incident rate calculation and expression are named and described in this article, and their advantages and disadvantages are delineated. Modest recommendations are made as to how researchers should use and express incident rates in the study of violence, absconding, self-harm, seclusion, constant observation, and other such behaviors.

Aversiveness of traditional psychiatric patient restriction

This article is a literature review of traditional psychiatric patient restriction and the consequential harm that the patient experiences. Though the obtainment of theoretical objectives and short-term overt behavioral results appear to be gained through psychiatric constraint measures, injurious effects to the patient have been recorded with resultant impediment to the restoration of psychological health. This article asserts the necessity for the use of alternative measures, which have been shown to be successful in restoring control while maintaining and promoting the dignity and psychological health of the patient.

A European perspective on psychiatric nursing and violent incidents: management, education and service organisation

The topic of violent incidents and its importance to inpatient psychiatric nursing practice is well recognised in the academic literature. However the awareness and profile of the issue in different European countries is highly variable. In this paper five European countries are compared: Italy, Norway, the Netherlands, Sweden and the UK. Contextual factors are likely to determine the perception, recognition and acknowledgement of the problem. Those described in detail here are the organisation of psychiatric inpatient services, the training of psychiatric nurses, and the methods used by those nurses to control and contain disturbed patients. For each of these factors large variations exist between the countries considered. The conclusion is drawn that there is much scope for useful comparative research.

Helping methods used by nurses in a psychiatric hospital environment

This qualitative study aims to describe the helping methods used by psychiatric nurses in a hospital environment from as evidenced by video observations and nurses' and patients' descriptions. The data, which were collected by videotaping different nursing situations and by interviewing the nurses and patients afterwards, consisted of 520 pages of written text. A total of 569 utterances were extracted from the text to describe the helping methods used in psychiatric nursing. Each utterance constituted a classification unit. Deductive content analysis techniques were used to analyze the data. The results obtained from the nurses' and patients' descriptions and the videotaped episodes showed that the most commonly used helping methods were of the confirmatory kind (50%), while educational methods came second (37%) and catalytic methods third (13%).

Alternatives to seclusion in psychiatric care

The use of seclusion in psychiatry is declining. Its punitive nature has been acknowledged and alternative, more therapeutic approaches are needed to deal with disturbed patients. What alternatives are available? This article reports a study that sought to examine the response to incidents that formerly would have led to seclusion in one psychiatric intensive care unit. The sample consisted of 50 incidents. Information on the incident and subsequent action was recorded on standard incident forms and specially designed data collection sheets. The most frequent type of incident was damage to property, followed by direct or threatened physical assault on staff. The most common response was one-to-one nursing support, followed by the use of medication. In just over half the incidents, both responses were used together. This therapeutic strategy demonstrates that aggressive incidents can be dealt with safely without recourse to seclusion.