The practice of seclusion and time-out on English acute psychiatric wards: the City-128 Study

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Developing nurse-sensitive outcomes in acute inpatient mental health settings-A systematic review

BACKGROUND

While nurse-sensitive outcomes (NSOs) are well established in numerous health settings, to date there is no indicator suite of NSOs for inpatient mental health settings.

AIM

To assess the relationship between nursing variables and patient outcomes in acute inpatient mental health settings to determine which outcomes can be used as indicators of the quality of nursing care.

METHODS

Databases accessed were CINAHL, MEDLINE, PsycINFO and EMBASE, last searched in May 2022. The review followed the 2020 PRISMA checklist for systematic reviews. Papers published between 1995 and 2022, conducted in acute mental health care units were included. The quality of the studies was assessed using the Effective Public Health Practice Project Quality Assessment Tool. A meta-analysis was not possible because of the large number of variables and measurement inconsistencies.

RESULTS

A total of 57 studies were reviewed. Studies were categorised according to whether they found a significant or non-significant relationship between nurse variables and patient outcomes. Seven outcomes-aggression, seclusion, restraint, absconding, pro-re-nata medications, special observations and self-harm-were identified. For each outcome, there were significant findings for several nurse variables indicating that all included outcomes could be used as NSOs. However, evidence for aggression, seclusion and restraint use as suitable NSOs was more robust than the evidence for self-harm, absconding, pro-re-nata medications and special observations.

CONCLUSION

All the seven outcomes can all be used to develop an NSO indicator suite in mental health inpatient settings. More work is needed to establish high-quality studies to clearly demonstrate the relationship between these outcome measures and changes in nurse variables such as nurse staffing, skill mix, work environment, nurse education and nurse experience.

PATIENT AND PUBLIC CONTRIBUTION

Patient or public contribution was not possible because of the type of the variables being explored.

Offenders and non-offenders with schizophrenia spectrum disorders: the crime-preventive potential of sufficient embedment in the mental healthcare and support system

Background

Suffering from schizophrenia spectrum disorder (SSD) has been well-established as a risk factor for offending. However, the majority of patients with an SSD do not show aggressive or criminal behavior. Yet, there is little research on clinical key features distinguishing offender from non-offender patients. Previous results point to poorer impulse control, higher levels of excitement, tension, and hostility, and worse overall cognitive functioning in offender populations. This study aimed to detect the most indicative distinguishing clinical features between forensic and general psychiatric patients with SSD based on the course of illness and the referenced hospitalization in order to facilitate a better understanding of the relationship between violent and non-violent offenses and SSD.

Methods

Our study population consisted of forensic psychiatric patients (FPPs) with a diagnosis of F2x (ICD-10) or 295.x (ICD-9) and a control group of general psychiatric patients (GPPs) with the same diagnosis, totaling 740 patients. Patients were evaluated regarding their medical (and, if applicable, criminal) history and the referenced psychiatric hospitalization. Supervised machine learning (ML) was used to exploratively evaluate predictor variables and their interplay and rank them in accordance with their discriminative power.

Results

Out of 194 possible predictor variables, the following 6 turned out to have the highest influence on the model: olanzapine equivalent at discharge from the referenced hospitalization, a history of antipsychotic prescription, a history of antidepressant, benzodiazepine or mood stabilizer prescription, medication compliance, outpatient treatment(s) in the past, and the necessity of compulsory measures. Out of the seven algorithms applied, gradient boosting emerged as the most suitable, with an AUC of 0.86 and a balanced accuracy of 77.5%.

Discussion

Our study aimed to identify the most influential illness-related predictors, distinguishing between FPP and GPP with SSD, thus shedding light on key differences between the two groups. To our knowledge, this is the first study to compare a homogenous sample of FPP and GPP with SSD regarding their symptom severity and course of illness using highly sophisticated statistical approaches with the possibility of evaluating the interplay of all factors at play.

Coercive measures in psychiatry - When do they occur and who is at risk?

Coercive measures (CM) in psychiatry adversely affect patients and efforts to minimize CM are steadily increasing. One area that has not been a strong focus of preventative efforts to date is the time of use of CM during hospitalization although previous research indicates that the admission situation and early hospitalization are times of increased risk for CM. This study therefore aims to contribute to the body of research in this field by analyzing in detail the times of use of CM and identifying patient characteristics serving as predictors for CM during early hospitalization. Using a large sample (N = 1556) of all cases admitted in 2019 via the emergency room at the Charité Department of Psychiatry at St. Hedwig Hospital in Berlin, this study supports previous research showing that the risk of CM is highest within the first 24 h h of hospitalization. Of 261 cases who experienced CM, 71.6% (n = 187) experienced a CM within the first 24 h of hospitalization and 54.4% (n = 142) of cases only experienced CM within the first 24 h of hospitalization and did not receive any CM after. Furthermore, this study identified significant predictors for the early use of CM during hospitalization including acute intoxication (p < .01), aggression (p < .01), male gender (p < .001) and limited communication ability (p < .001). The results highlight the importance of directing preventative efforts to minimize the use of CM not only to psychiatric units but also to mental health crisis response and to develop interventions specifically tailored to this time and patient groups at highest risk.

Predictors of the use of restraint in inpatient psychiatric care among patients admitted via the emergency department

BACKGROUND

Coercive measures are associated with negative consequences for both patients and hospital staff. The aim of the study was to identify predictors for the use of restraints in the emergency department and in subsequent inpatient care.

METHOD

Retrospective routine clinical data of all patients admitted to the psychiatric departments of Vivantes Klinikum Am Urban in Berlin via the emergency department in 2019 was examined case-wise (n = 2584) as well as patient-wise (n = 2118).

RESULTS

Of all cases admitted via the emergency department, 195 cases (7.5%) experienced restraints and restraints combined with drug sedation during their inpatient treatment. Of the 2584 cases admitted via the emergency department, 195 cases (7.5%) experienced restraints and restraints combined with drug sedation during their inpatient treatment. These 195 cases experienced a total of 358 restraints and were distributed across 159 individuals. Multivariate regression analyses on patient-level show that age (p < .001), judicial placement (p < .001), and police referral in the presence of others (p < .001) had a statistically significant effect on the use of restraint.

DISCUSSION

The results indicate that certain patient characteristics increase the risk of restraints. A majority of the findings of this study underline previous research findings. However, ICD-10 diagnosis and gender do not prove to be significant variables, contrary to expectations based on previous.

Ethnic disparities in the use of restrictive practices in adult mental health inpatient settings: a scoping review

PURPOSE

To identify and summarise extant knowledge about patient ethnicity and the use of various types of restrictive practices in adult mental health inpatient settings.

METHODS

A scoping review methodological framework recommended by the JBI was used. A systematic search was conducted in APA PsycINFO, CINAHL with Full Text, Embase, PubMed and Scopus. Additionally, grey literature searches were conducted in Google, OpenGrey and selected websites, and the reference lists of included studies were explored.

RESULTS

Altogether, 38 studies were included: 34 were primary studies; 4, reviews. The geographical settings were as follows: Europe (n = 26), Western Pacific (n = 8), Americas (n = 3) and South-East Asia (n = 1). In primary studies, ethnicity was reported according to migrant/national status (n = 16), mixed categories (n = 12), indigenous vs. non-indigenous (n = 5), region of origin (n = 1), sub-categories of indigenous people (n = 1) and religion (n = 1). In reviews, ethnicity was not comparable. The categories of restrictive practices included seclusion, which was widely reported across the studies (n = 20), multiple restrictive practices studied concurrently (n = 17), mechanical restraint (n = 8), rapid tranquillisation (n = 7) and manual restraint (n = 1).

CONCLUSIONS

Ethnic disparities in restrictive practice use in adult mental health inpatient settings has received some scholarly attention. Evidence suggests that certain ethnic minorities were more likely to experience restrictive practices than other groups. However, extant research was characterised by a lack of consensus and continuity. Furthermore, widely different definitions of ethnicity and restrictive practices were used, which hampers researchers' and clinicians' understanding of the issue. Further research in this field may improve mental health practice.

Nursing staff composition and its influence on seclusion in an adult forensic mental health inpatient setting: The truth about numbers

INTRODUCTION

Research on the influence of nursing staff composition and use of seclusion in the forensic mental health inpatient settings is sparse. Nursing staff composition refers to staffing levels, roles, gender ratio and skill mix of the ward teams. Internationally, the rates of seclusion in some forensic mental health inpatient settings have increased over the past 10 years despite global efforts to reduce and eliminate its use.

AIM

To examine whether the use of seclusion in a forensic mental health inpatient setting can be attributed to staffing composition or to contextual factors such as day of the week, month or other clinical factors.

METHOD

Retrospective data collection was conducted using seclusion data, daily ward reports and staff rosters. Data were collected for all shifts in the hospital over a six-month period.

RESULTS

Three staffing variables were identified as having an influence on the use of seclusion: the number of registered nurses on duty, the presence of the shift coordinator and having a lead nurse on shift.

DISCUSSION

Senior nurse oversight and guidance are important factors in assisting staff to identify clinical deterioration and intervene early which may assist services reduce the use of seclusion.

IMPLICATIONS FOR PRACTICE

As staffing levels and composition are modifiable, the results of this study may assist nurse leaders to consider workforce improvements to reduce seclusion use.

Patient communication ability as predictor of involuntary admission and coercive measures in psychiatric inpatient treatment

Coercive measures (CM) and involuntary admission to psychiatric treatment can have detrimental consequences for patients. Past research shows that certain clinical, treatment and admission-related characteristics put patients at a higher risk of experiencing CM and involuntary admission. Although of high societal importance, the association between patients' communication ability and CM and involuntary admission has not been subject of past research. To explicitly examine this association the authors conducted a retrospective study using data from patients admitted to psychiatric inpatient treatment via the emergency room at Charité St. Hedwig Hospital, Berlin in 2019. As independent variable, communication ability at admission was recorded (perfect; limited due to language or other reasons; impossible due to language or other reasons) along with possibly confounding variables including demographic, clinical and admission-related details. As dependent variables, involuntary admission and CM were recorded. Multivariate logistic regression analyses were conducted examining the association between communication ability and involuntary admission and CM. In a sample of N = 1556, controlling for potential confounders, limited (OR = 3.08; p = .004) or no communication ability (OR = 4.02; p = .003) due to language barrier or limited (OR = 3.10; p < .001) or no communication ability (OR = 13.71; p < .001) due to other factors were significant predictors for involuntary admission. Limited communication ability due to language barrier (OR = 4.53; p < .001) and limited (OR = 1.58; p = .034) and no communication ability (OR = 3.55; p < .001) due to other factors were significant predictors for CM. These findings show that patients impaired in their communication ability are at higher risk of involuntary admission and CM and highlight the urgency of implementing appropriate interventions facilitating communication during admission and treatment.

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.

Measuring Staff Attitudes to Coercion in Poland

Introduction: Coercion can be defined as the use of force to limit a person's choices. In Poland, coercive measures may tend to be overused. However, there is limited information regarding the attitudes of nurses toward coercion in psychiatric settings and the factors influencing any decisions to use coercion. Aims: To validate the Staff Attitudes to Coercion Scale (SACS) for a group of psychiatric nurses and psychiatrists, to compare the said with the original Norwegian SACS version, and to compare nurses' attitudes with those displayed by psychiatrists. A second aim was to understand the relationship between self-efficacy and attitudes to coercion. Method: We surveyed 351 psychiatric nurses and psychiatrists rating SACS and GSES (General Self Efficacy Scale). We validated the SACS factor structure using confirmatory principal component factor analysis, calculated the internal consistency of subscales, and analyzed the test-retest reliability and face validity of the subscales themselves. Further, we analyzed the differences in attitudes toward coercion between nurses and psychiatrists, as well as whether there was an association between GSES and the SACS subscales. We compared the means on the SACS items between three countries-Germany, Norway, and Poland. Results: The confirmatory factor analysis of the Polish version of SACS found the same factor structure with three factors as was displayed in the original Norwegian SACS, except that one item was loaded on another factor. Internal consistency was acceptable for the factors on coercion as security and the coercion as offending, and unacceptable for the factor on coercion as treatment. Test-retest reliability was excellent for all the three subscales. Face validity was high for the factor coercion as security, partly present for coercion as offending, and not present for coercion as treatment. The subscale Coercion as Treatment was rated significantly higher by nurses than by psychiatrists, but there was no difference for the two other subscales. There was no significant association between the General Self-Efficacy Scale and any of the SACS subscales. The biggest differences in attitudes toward forms of coercion was noted between Poland and Germany. Discussion: The three-factor structure of SACS was the best solution for the Polish nurses and psychiatrists. The attitudes toward coercion differed between the two groups, but a low correlation was computed for the SACS subscales and self-efficacy. There is a cultural diversity visible amongst the three countries examined. Reduction in the use of coercion is a priority worldwide. More knowledge about the process involved in using coercive measures may contribute to this. The use of coercive interventions may harm patients and threaten patients' rights. Thus, education is needed for pre-service and in-service nurses alike.

Influence of nursing staff characteristics on seclusion in acute mental health care-A prospective two-year follow-up study

INTRODUCTION

Seclusion still occurs on mental health wards, despite absence of therapeutic efficacy and high risks of adverse patient effects. Literature on the effect of nursing teams, and the role of psychological characteristics in particular, on frequency of seclusion is scarce.

AIM

To explore the influence of demographic, professional or psychological, nursing team-level, and shift characteristics on the frequency of use of seclusion.

METHODS

Prospective two-year follow-up study.

RESULTS

We found that the probability of seclusion was lower when nursing teams with at least 75% males were on duty, compared to female only teams, odds ratio (OR = 0.283; 95% CrI 0.046-0.811). We observed a trend indicating that teams scoring higher on the openness personality dimension secluded less, (OR = 0.636; 95% CrI 0.292-1.156).

DISCUSSION

Higher proportions of male nurses in teams on duty were associated with lower likelihood of seclusion. We found an indication that teams with a higher mean openness personality trait tended to seclude less. These findings, if causal, could serve as an incentive to reflect on staff mix if circumstances demand better prevention of seclusion.

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.

Design features that reduce the use of seclusion and restraint in mental health facilities: a rapid systematic review

Increasing efforts are being made to prevent and/or eliminate the use of seclusion and restraint in mental health facilities. Recent literature recognises the importance of the physical environment in supporting better outcomes in mental health services. This rapid review scoped the existing literature studying what physical design features of mental health facilities can reduce the use of seclusion and physical restraint.

DESIGN

A rapid review of peer-reviewed literature.

METHODS

Peer-reviewed literature was searched for studies on architectural design and the use of restraint and seclusion in mental health facilities. The following academic databases were searched: Cochrane Library, Medline, PsycINFO, Scopus and Avery for English language literature published between January 2010 and August 2019. The Joanna Briggs Institute's critical appraisal tool was used to assess the quality of included studies.

RESULTS

We identified 35 peer-reviewed studies. The findings revealed several overarching themes in design efforts to reduce the use of seclusion and restraint: a beneficial physical environment (eg, access to gardens or recreational facilities); sensory or comfort rooms; and private, uncrowded and calm spaces. The critical appraisal indicated that the overall quality of studies was low, as such the findings should be interpreted with caution.

CONCLUSION

This study found preliminary evidence that the physical environment has a role in supporting the reduction in the use of seclusion and restraint. This is likely to be achieved through a multilayered approach, founded on good design features and building towards specific design features which may reduce occurrences of seclusion and restraint. Future designs should include consumers in a codesign process to maximise the potential for change and innovation that is genuinely guided by the insights of lived experience expertise.

Nurse and patient factors: Predicting seclusion in adolescent psychiatric units

PROBLEM

Seclusion is considered a necessity when alternatives have failed. There is a consensus that seclusion has no therapeutic benefit, which justifies efforts to reduce the practice. This study aimed to identify nurse and patient variables that are predictive of seclusion on a large adolescent inpatient unit.

METHODS

Nested case controls were used to compare 72 afternoon shifts on which seclusion occurred to 216 afternoon shifts on which no seclusion occurred, between 2010 and 2013, at an Adolescent Psychiatric Inpatient Unit.

FINDINGS

Increased seclusion was predicted by a lower nurse to patient ratio, more male nurses on shift, fewer female nurses on shift, the presence of agency/temporary nurses on shift, greater combined years of mental health experience, and lower total HoNOSCA behavior subscale score. Unique predictors that increased risk of seclusion included greater number of male nurses and the presence of agency/temporary nurses, while a greater number of female nurses decreased risk of seclusion.

CONCLUSIONS

Nurses play a unique role in seclusion outcomes that are separate to patient-factors and act as both protective and risk factors for seclusion. Changes can be made to staffing to reduce seclusion and future research should investigate why these nurse-factors contribute to seclusion.

Correlates of seclusion and restraint of patients admitted to psychiatric inpatient treatment via a German emergency room

Coercive measures in psychiatry are associated with negative consequences for both patients and staff. When it comes to preventing coercive measures, innovative models of care like the Weddinger Modell focusing on recovery, participation and supported decision-making have proven successful. However, observations from clinical practice show that emergency admissions to psychiatric facilities pose a great challenge in this regard and that most coercive measures take place during or shortly after emergency admission. This study retrospectively examined all cases (N = 1477) admitted to inpatient treatment at the Department of Psychiatry of the Charité at St. Hedwig Hospital in Berlin via the emergency room in 2018 aiming to identify patient characteristics that serve as predictors for coercive measures. Physical aggression, involuntary admission, police referral and younger age were found to be significant predictors (p < .001). Of 218 cases who experienced coercive measures, 81.2% (n = 177) were subjected to seclusion or restraint within the first 24 h of their hospital stay and 56.9% (n = 124) of cases only experienced coercive measures within these first 24 h and were not subjected to any coercive measures after. These results show that certain patient characteristics put individuals at higher risk of being secluded or restrained and that the risk of experiencing coercive measures is highest at the time during and shortly after emergency admission. To prevent coercive measures, it is crucial to target more resources and put in place measures specifically tailored to these emergency situations and the most vulnerable patient groups.

Use of coercion prevention tools in Finnish psychiatric wards

Inpatient violence is a widespread problem in psychiatric wards and has often serious consequences. Literature indicates that de-escalation techniques are the recommended first-line intervention for managing violence, are widely used to reduce it, and restrictive practices in mental health settings. However, these techniques and models are not used at the optimum frequency and/or important factors are limiting their use and effectiveness. We aimed to determine what kind of de-escalation methods are used to reduce violence and coercion in Finnish psychiatric hospitals. Descriptive qualitative research using semi-structured questionnaires and Framework Analysis was used. The results of the study are reported in quantitative terms. A survey of psychiatric wards (N = 65) in Finland's hospital districts (n = 16) was conducted in the Autumn of 2019 to find out which de-escalation models are used. Finnish psychiatric wards use both the Safewards and Six Core Strategies models to reduce violence and the use of restrictive practices. Half of the hospitals used interventions and strategies from both models. Violence preventive methods are widely used in mental health settings in Finland. These interventions and models cover the organization, leadership, and patient perspectives to improve safety and decrease coercion actions in psychiatric wards.

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

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

Identifying Direct Coercion in a High Risk Subgroup of Offender Patients With Schizophrenia via Machine Learning Algorithms

PURPOSE

This study aims to explore risk factors for direct coercive measures (seclusion, restraint, involuntary medication) in a high risk subpopulation of offender patients with schizophrenia spectrum disorders.

METHODS

Five hundred sixty nine potential predictor variables were explored in terms of their predictive power for coercion/no coercion in a set of 131 (36.6%) offender patients who experienced coercion and 227 who did not, using machine learning analysis. The dataset was split (70/30%) applying variable filtering, machine learning model building, and selection embedded in nested resampling approach in one subset. The best model was then selected, and the most important variables extracted on the second data subset.

RESULTS

In the final model the following variables identified coercion with a balanced accuracy of 73.28% and a predictive power (area under the curve, AUC) of 0.8468: threat of violence, (actual) violence toward others, the application of direct coercive measures during past psychiatric inpatient treatments, the positive and negative syndrome scales (PANSS) poor impulse control, uncooperativeness, and hostility and the total PANSS-score at admission, prescription of haloperidol during inpatient treatment, the daily cumulative olanzapine equivalent antipsychotic dosage at discharge, and the legal prognosis estimated by a team of licensed forensic psychiatrists.

CONCLUSIONS

Results confirm prior findings, add detail on factors indicative for the use of direct coercion, and provide clarification on inconsistencies. Limitations, clinical relevance, and avenues for future research are discussed.

Psychiatric nursing staffs' attitudes towards the use of containment methods in psychiatric inpatient care: An integrative review

One of the international objectives in psychiatric care is reducing the use of coercion. Containment methods are meant to keep patients safe, yet usually include coercion. Nurses play a key role in deciding whether or not containment should be used and, as such, their attitudes towards containment can significantly impact the extent to which these methods are applied. The aim of this integrative review was to identify, analyse, and synthesize the available research on psychiatric nursing staffs' attitudes towards containment methods in inpatient psychiatric care. An electronic search was conducted using the CINAHL, Scopus, and PsycINFO databases. In addition, the citations of identified studies were screened for relevant research. A total of 24 relevant papers published between 2002 and 2017 were selected for further analysis. These studies revealed variation in nursing staffs' attitudes towards the use of containment methods. The use of containment methods seems to be widely accepted and nurses reported rarely considering alternative measures. It appears that attitudes towards containment have continuously become more negative, although the change has not been very pronounced. The concept of attitude was only defined in two studies. Thus, future research should strive to clarify this concept, as a generally accepted definition for attitude within nursing research and the utilization of all dimensions of this concept are both essential to the nursing field. Currently, it would be important to focus on changing attitudes among psychiatric nursing staff to reduce the use of containment methods; this calls for more research on nursing staffs' attitudes.

Variation in seclusion rates across New Zealand's specialist mental health services: Are sociodemographic and clinical factors influencing this?

Rates of seclusion vary across New Zealand's publicly funded district health board (DHB) adult mental health inpatient services as indicated by national data. Anecdotally, this variation has been attributed to a range of factors directly relating to the people admitted to acute inpatient services. This study examined the extent to which variation in seclusion rates could be explained by the sociodemographic and clinical differences between populations admitted into adult mental health inpatient services. Retrospective data were obtained from the Programme for the Integration of Mental Health Data (PRIMHD). A logistic regression model was fitted to these data, with seclusion (yes/no) as the dependent variable and DHB groups as the independent variable. The DHBs were classified into four groups based on their seclusion rates. The model adjusted for ethnicity, age, number of bed nights, total Health of the Nation Outcome Scales (HoNOS) scores, and compulsory treatment status. Odds ratios remained virtually unchanged after adjustment for sociodemographic and clinical factors. People admitted to DHB Group 4 (highest secluding DHBs) were 11 times more likely to be secluded than people in Group 1 (lowest secluding DHBs), adjusted OR = 11.1, 95% CI [7.5,16.4], P < 0.001. Results indicate DHB variation in seclusion rates cannot be attributed to the sociodemographic and clinical factors of people admitted into DHB adult mental health inpatient services. Instead, this variation may be explained by differences in service delivery models and practice approaches. A model of system improvements aimed at reducing seclusion is discussed.

People who experience seclusion in adult mental health inpatient services: An examination of health of the nation outcome scales scores

The Health of the Nation Outcomes Scales (HoNOS) provides an overview of a person's behaviour, impairment, clinical symptoms, and social functioning. This study investigated the profile of people who had been secluded in New Zealand's adult mental health inpatient services using 12 individual HoNOS ratings. Routinely collected clinical data were extracted from the Programme for the Integration of Mental Health Data (PRIMHD). This is the national data set for mental health and addiction services. A logistic regression model was fitted to the data which adjusted for age, sex, ethnicity, bed nights, compulsory treatment, and district health board. After adjustment, three HoNOS items significantly predicted the risk of seclusion: overactive, aggressive, disruptive, or agitated behaviour (adjusted OR = 4.82, 95% CI [3.88, 5.97], P < 0.001); problem drinking or drug-taking (adjusted OR = 1.51, 95% CI [1.25, 1.82], P < 0.001); and problems with hallucinations and delusions (adjusted OR = 1.33, 95% CI [1.09, 1.63], P = 0.006). In addition, two HoNOS items were protective for seclusion: nonaccidental self-injury (adjusted OR = 0.65, 95% CI [0.51, 0.83], P < 0.001) and depressed mood (adjusted OR = 0.58, 95% CI [0.47, 0.72], P < 0.001). Thus, responding effectively to agitation and/or aggression, substance use, and psychosis plays an important role in reducing the use of seclusion. Mental health nurses and other workers can reduce seclusion through early assessment, effective communication, de-escalation techniques, reduction tools, trauma-informed care, and consulting with consumers and whānau.

Brazilian guidelines for the management of psychomotor agitation. Part 1. Non-pharmacological approach

Objective:

To present the essential guidelines for non-pharmacological management of patients with psychomotor agitation in Brazil.

Methods:

These guidelines were developed based on a systematic review of articles published from 1997 to 2017, retrieved from MEDLINE (PubMed), Cochrane Database of Systematic Review, and SciELO. Other relevant articles identified by searching the reference lists of included studies were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools.

Results:

We initially selected 1,731 abstracts among 5,362 articles. The final sample included 104 articles that fulfilled all the inclusion criteria. The management of agitated patients should always start with the least coercive approach. The initial non-pharmacological measures include a verbal strategy and referral of the patient to the appropriate setting, preferably a facility designed for the care of psychiatric patients with controlled noise, lighting, and safety aspects. Verbal de-escalation techniques have been shown to decrease agitation and reduce the potential for associated violence in the emergency setting. The possibility of underlying medical etiologies must be considered first and foremost. Particular attention should be paid to the patient’s appearance and behavior, physical signs, and mental state. If agitation is severe, rapid tranquilization with medications is recommended. Finally, if verbal measures fail to contain the patient, physical restraint should be performed as the ultimate measure for patient protection, and always be accompanied by rapid tranquilization. Healthcare teams must be thoroughly trained to use these techniques and overcome difficulties if the verbal approach fails. It is important that healthcare professionals be trained in non-pharmacological management of patients with psychomotor agitation as part of the requirements for a degree and graduate degree.

Conclusion:

The non-pharmacological management of agitated patients should follow the hierarchy of less invasive to more invasive and coercive measures, starting with referral of the patient to an appropriate environment, management by a trained team, use of verbal techniques, performance of physical and mental assessment, use of medications, and, if unavoidable, use of the mechanical restraint.

Systematic review registry number:

CRD42017054440.

Fear and blame in mental health nurses' accounts of restrictive practices: Implications for the elimination of seclusion and restraint

Restrictive practices continue to be used in mental health care despite increasing recognition of their harms and an international effort to reduce and ultimately eliminate their use. The aim of this qualitative study was to explore mental health nurses' views of the potential elimination of these practices. Nine focus groups were conducted with 44 mental health nurses across Australia, and the data analysed using thematic analysis. Overall, the nurses expressed significant fear about the potential elimination of restrictive practices and saw themselves as being blamed for both the use of these practices and the consequences should they be eliminated. Findings detail the conflicts facing staff in balancing the need for ward safety for everyone present while at the same time providing person-centred care. Nurses described the changing role of the mental health nurse in acute settings, being more focussed on risk assessment and medication while at the same time attempting to practise in trauma-informed person-centred ways. The impact on ward safety with increasing acuity of consumers plus the presence of forensic consumers and those affected by methamphetamine was emphasized. Change initiatives need to take into account nurses' deep concerns about the consequences of eliminating all forms of control measures in hospitals and respond to the symptoms and behaviours consumers present with and associated unpredictable and concerning behaviours. Attempts to eliminate restrictive practices should, therefore, be carefully considered and come with a clear articulation of alternatives to ensure the safety of consumers, visitors, and staff.

Cross-sectional study on nurses' attitudes regarding coercive measures: the importance of socio-demographic characteristics, job satisfaction, and strategies for coping with stress

BACKGROUND

Coercive measures are containment methods used in psychiatry to curb patients' disruptive and aggressive behaviours towards themselves, others or objects. The prevalence of the practice of coercive measures in psychiatry is directly related to the attitudes of the staff. When discussing these attitudes, nurses are often particularly singled out. The purpose of the study is to research the impact of individual factors on nurses' attitudes in the decision-making process for the use of coercive measures.

METHODS

A cross-sectional study among all psychiatric nursing staff in Slovenia (n = 367, 79%) was conducted over the years 2013/2014. Standardized questionnaires were used, including a survey of nurses' attitudes to the use of seclusion, the Job Descriptive Index, and the Folkman-Lazarus test.

RESULTS

Nurses' attitudes towards special coercive measures are predominantly negative ([Formula: see text] = 11.312, SD = 2.641). The factors that explain a positive attitude are as follows: female gender (β = - 0.236, p <  0.001), fewer years of service (β = - 0.149, p = 0.023), emotion-focused strategies of coping with stress (β = 0.139, p = 0.020), and less-threatening patient behaviour (β = 0.157, p = 0.012).

CONCLUSIONS

The effects of some known factors did not prove important in the model. Newly recognized factors are "less-threatening patient behaviour" and "emotion-focused strategies of coping with stress". Therefore, attitudes towards special coercive measures in psychiatry must be regarded as contextualized, interactive, and multidimensional phenomena that cannot be explained merely through a defined set of factors.

Consumers' and their supporters' perspectives on barriers and strategies to reducing seclusion and restraint in mental health settings

Objective This paper examines the perspectives of consumers and their supporters regarding the use of seclusion and restraint in mental health settings. Methods Five focus groups for consumers and five focus groups for supporters were conducted in four Australian cities and in one rural location. The 66 participants were asked about strategies to reduce or eliminate the use of seclusion and restraint in mental health settings. Results All participants supported the reduction of the use of seclusion and restraint. Barriers to reducing these practices related to the environment, the effects of drug and alcohol issues, lack of a human rights focus and poor recognition of trauma, stigma and discrimination. Strategies for reducing or eliminating seclusion and restraint included workforce development, environmental and cultural changes. Conclusions Participants clearly identified that the status quo needs to change and conveyed urgency for action. Participants suggested that the involvement of supporters and a range of consumer roles are integral to reducing the use of seclusion and restraint. The findings support the current policy emphasis of working towards the elimination of these practices. What is known about the topic? Mental health policies across many jurisdictions support the reduction and elimination of restraint and seclusion. Evidence suggests those subjected to restraint and seclusion largely experience a range of harmful consequences. No studies focus on the views of supporters of consumers regarding the reduction and elimination of seclusion and restraint, whereas the views of consumers appear in a minority of international studies. What does this paper add? The research enabled an opportunity to hear from people who have been personally affected by and/or have lived experience of these coercive practices. Participants identified local reforms that can uphold the human rights of consumers. They suggested practices to increase accountability, peer support and family involvement, areas that have not been analysed in depth in any of the seclusion and restraint literature. What are the implications for practitioners? This paper will give healthcare services a deeper insight into how to reduce or eliminate restraint or seclusion from the perspective of those with lived experience.

Machine Learning: An Approach in Identifying Risk Factors for Coercion Compared to Binary Logistic Regression

Introduction: Although knowledge about negative effects of coercive measures in psychiatry exists, its prevalence is still high in clinical routine. This study aimed at define risk factors and test machine learning algorithms for their accuracy in the prediction of the risk to being subjected to coercive measures. Methods: In a sample of involuntarily hospitalized patients (n = 393) at the University Hospital of Psychiatry Zurich, we analyzed risk factors for the experience of coercion (n = 170 patients) using chi-square tests and Mann Whitney U tests. We trained machine learning algorithms [logistic regression, Supported Vector Machine (SVM), and decision trees] with these risk factors and tested obtained models for their accuracy via five-fold cross validation. To verify the results we compared them to binary logistic regression. Results: In a model with 8 risk-factors which were available at admission, the SVM algorithm identified 102 out of 170 patients, which had experienced coercion and 174 out of 223 patients without coercion (69% accuracy with 60% sensitivity and 78% specificity, AUC 0.74). In a model with 18 risk-factors, available after discharge, the logistic regression algorithm identified 121 out of 170 with and 176 out of 223 without coercion (75% accuracy, 71% sensitivity, and 79% specificity, AUC 0.82). Discussion: Incorporating both clinical and demographic variables can help to estimate the risk of experiencing coercion for psychiatric patients. This study could show that trained machine learning algorithms are comparable to binary logistic regression and can reach a good or even excellent area under the curve (AUC) in the prediction of the outcome coercion/no coercion when cross validation is used. Due to the better generalizability machine learning is a promising approach for further studies, especially when more variables are analyzed. More detailed knowledge about individual risk factors may help to prevent the occurrence of situations involving coercion.

Comparing Attitudes to Containment Measures of Patients, Health Care Professionals and Next of Kin

Background: In clinical psychiatric practice, health care professionals (HCP) must decide in exceptional circumstances after the weighing of interests, which, if any, containment measures including coercion are to be used. Here, the risk for patients, staff, and third parties, in addition to therapeutic considerations, factor into the decision. Patients' preference and the inclusion of relatives in these decisions are important; therefore, an understanding of how patients and next of kin (NOK) experience different coercive measures is crucial for clinical decision making. The aim of this study is to compare how patients, HCP, and NOK assess commonly used coercive measures. Methods: A sample of 435 patients, 372 HCP, and 230 NOK completed the Attitudes to Containment Measures Questionnaire (ACMQ). This standardized self-rating questionnaire assessed the degree of acceptance or rejection of 11 coercive measures. Results: In general, HCPs rated the coercive measures as more acceptable than did NOK and patients. The largest discrepancy in the ratings was found in regard to the application of coercive intramuscular injection of medication (effect size: 1.0 HCP vs. patients). However, the ratings by NOK were significantly closer to the patients' ratings compared to patients and HCP. The only exception was the acceptance of treatment in a closed acute psychiatric ward, which was deemed significantly more acceptable by NOK than by patients. Also, patients who had experienced coercive measures themselves more strongly refused other measures. Conclusion: Patients most firmly rejected intramuscular injections, and the authors agree that these should only be used with reservation considering a high threshold. This knowledge about the discrepancy of the ratings should therefore be incorporated into professional training of HCP.

De-escalation techniques used, and reasons for seclusion and restraint, in a forensic psychiatric hospital

In Finland, the Mental Health Act determines the legal basis for seclusion and restraint. Restrictive measures are implemented to manage challenging situations and should be used as a last resort in psychiatric inpatient care. In the present study, we examined the reasons for seclusion and restraint, as well as whether any de-escalation techniques were used to help patients calm down. Seclusion and restraint files from a 4-year period (1 June 2009-31 May 2013) were retrospectively investigated and analysed by content analysis. Descriptive statistics were calculated. A total of 144 episodes of seclusion and restraint were included to analyse the reasons for seclusion and restraint, and 113 episodes were analysed to examine unsuccessful de-escalation techniques. The most commonly-used techniques were one-to-one interaction with a patient (n = 74, 65.5% of n = 113) and administration of extra medication (n = 37, 32.7% of n = 113). The reasons for seclusion and restraint were threatening harmful behaviour (n = 51, 35.4% of n = 144), direct harmful behaviour (n = 43, 29.9%), indirect harmful behaviour (n = 42, 29.1%), and other behaviours (n = 8, 5.6%). In general, the same de-escalation techniques were used with most patients. Most episodes of seclusion or restraint were due to threats of violence or direct violence. Individual means of self-regulation and patient guidance on these techniques are needed. Additionally, staff should be educated on a diverse range of de-escalation techniques. Future studies should focus on examining de-escalation techniques for the prevention of seclusion.

Associations between psychiatric symptoms and seclusion use: Clinical implications for care planning

Findings from an increasing number of studies suggest that incorporating systematic short-term risk assessments in treatment planning could lead to safer practice on psychiatric admissions wards. The aim of the present study was to investigate the associations between the scores of three structured observation tools - the Kennedy Axis V (K-Axis-V), the Brief Psychiatric Rating Scale (BPRS), and the Social Dysfunction and Aggression Scale (SDAS) - and seclusion. In total, 1840 weekly risk assessments with these observation scales were collected over 2342 admission weeks. These assessment scores related to 370 acutely-admitted psychiatric patients and were subjected to a multilevel analysis. It was found that several dynamic and static factors were related to seclusion. Dynamic factors included violent behaviour, current substance abuse, suspiciousness, and negativism. Static factors included ethnicity and having been diagnosed with a substance abuse disorder. The findings suggest that the incorporation of the Kennedy-Axis V, the BPRS, and the SDAS into standard practice might be helpful in identifying patients at high risk of seclusion, and could be supportive to treatment planning and clinical decision-making in the prevention of seclusion use in acute psychiatric settings.

Nursing Staff Factors Contributing to Seclusion in Acute Mental Health Care - An Explorative Cohort Study

BACKGROUND

Seclusion is a controversial intervention. Efficacy with regard to aggressive behaviour has not been demonstrated, and seclusion is only justified for preventing safety hazards. Previous studies indicate that nursing staff factors may be predictors for seclusion, although methodological issues may have led to equivocal results.

OBJECTIVE

To perform a prospective cohort study to determine whether nursing staff characteristics are associated with seclusion of adult inpatients admitted to a closed psychiatric ward.

METHOD

We studied the association between nurses' demographics and incidence of seclusion during every shift. Data were collected during five months in 2013. Multiple logistic regression was used for analysis.

RESULTS

In univariable analysis, we found a non-significant association between seclusion and female gender, odds ratio (OR) = 5.27 (0.98-28.49) and a significant association between seclusion and nurses' large physical stature, OR = 0.21 (0.06-0.72). We found that physical stature is the most substantial factor, although not significant: OR_adjusted = 0.27 (0.07-1.04).

CONCLUSION

Nurses' gender may be a predictor for seclusion, but it seems to be mediated by the effect of physical stature. We used a rigorous, census-based, prospective design to collect data on a highly detailed level and found a large effect of physical stature of nurses on seclusion. We found nurses' physical stature to be the most substantial predictor for seclusion. These and other factors need to be explored in further research with larger sample size.

Seclusion and Psychiatric Intensive Care Evaluation Study (SPICES): combined qualitative and quantitative approaches to the uses and outcomes of coercive practices in mental health services

Background

Seclusion (the isolation of a patient in a locked room) and transfer to a psychiatric intensive care unit (PICU; a specialised higher-security ward with higher staffing levels) are two common methods for the management of disturbed patient behaviour within acute psychiatric hospitals. Some hospitals do not have seclusion rooms or easy access to an on-site PICU. It is not known how these differences affect patient management and outcomes.

Objectives

To (1) assess the factors associated with the use of seclusion and PICU care, (2) estimate the consequences of the use of these on subsequent violence and costs (study 1) and (3) describe differences in the management of disturbed patient behaviour related to differential availability (study 2).

Design

The electronic patient record system at one trust was used to compare outcomes for patients who were and were not subject to seclusion or a PICU, controlling for variables, including recent behaviours. A cost-effectiveness analysis was performed (study 1). Nursing staff at eight hospitals with differing access to seclusion and a PICU completed attitudinal measures, a video test on restraint-use timing and an interview about the escalation pathway for the management of disturbed behaviour at their hospital. Analyses examined how results differed by access to PICU and seclusion (study 2).

Participants

Patients on acute wards or PICUs in one NHS trust during the period 2008–13 (study 1) and nursing staff at eight randomly selected hospitals in England, with varying access to seclusion and to a PICU (study 2).

Main outcome measures

Aggression, violence and cost (study 1), and utilisation, speed of use and attitudes to the full range of containment methods (study 2).

Results

Patients subject to seclusion or held in a PICU were more likely than those who were not to be aggressive afterwards, and costs of care were higher, but this was probably because of selection bias. We could not derive satisfactory estimates of the causal effect of either intervention, but it appeared that it would be feasible to do so for seclusion based on an enriched sample of untreated controls (study 1). Hospitals without seclusion rooms used more rapid tranquillisation, nursing of the patient in a side room accompanied by staff and seclusion using an ordinary room (study 2). Staff at hospitals without seclusion rated it as less acceptable and were slower to initiate manual restraint. Hospitals without an on-site PICU used more seclusion, de-escalation and within-eyesight observation.

Limitations

Official record systems may be subject to recording biases and crucial variables may not be recorded (study 1). Interviews were complex, difficult, constrained by the need for standardisation and collected in small numbers at each hospital (study 2).

Conclusions

Closing seclusion rooms and/or restricting PICU access does not appear to reduce the overall levels of containment, as substitution of other methods occurs. Services considering expanding access to seclusion or to a PICU should do so with caution. More evaluative research using stronger designs is required.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice

The discourse of safety has informed the care of individuals with mental illness through institutionalization and into modern psychiatric nursing practices. Confinement arose from safety: out of both societal stigma and fear for public safety, as well as benevolently paternalistic aims to protect individuals from self‐harm. In this paper, we argue that within current psychiatric inpatient environments, safety is maintained as the predominant value, and risk management is the cornerstone of nursing care. Practices that accord with this value are legitimized and perpetuated through the safety discourse, despite evidence refuting their efficacy, and patient perspectives demonstrating harm. To illustrate this growing concern in mental health nursing care, we provide four exemplars of risk management strategies utilized in psychiatric inpatient settings: close observations, seclusion, door locking and defensive nursing practice. The use of these strategies demonstrates the necessity to shift perspectives on safety and risk in nursing care. We suggest that to re‐centre meaningful support and treatment of clients, nurses should provide individualized, flexible care that incorporates safety measures while also fundamentally re‐evaluating the risk management culture that gives rise to and legitimizes harmful practices.

Acceptability and use of coercive methods across differing service configurations with and without seclusion and/or psychiatric intensive care units

Aims

The aim of this study was to compare across different service configurations the acceptability of containment methods to acute ward staff and the speed of initiation of manual restraint.

Background

One of the primary remits of acute inpatient psychiatric care is the reduction in risks. Where risks are higher than normal, patients can be transferred to a psychiatric intensive care unit or placed in seclusion. The abolition or reduction in these two containment methods in some hospitals may trigger compensatory increases in other forms of containment which have potential risks. How staff members manage risk without access to these facilities has not been systematically studied.

Design

The study applied a cross‐sectional design.

Methods

Data were collected from 207 staff at eight hospital sites in England between 2013 ‐ 2014. Participants completed two measures; the first assessing the acceptability of different forms of containment for disturbed behaviour and the second assessing decision‐making in relation to the need for manual restraint of an aggressive patient.

Results

In service configurations with access to seclusion, staff rated seclusion as more acceptable and reported greater use of it. Psychiatric intensive care unit acceptability and use were not associated with its provision. Where there was no access to seclusion, staff were slower to initiate restraint. There was no relationship between acceptability of manual restraint and its initiation.

Conclusion

Tolerance of higher risk before initiating restraint was evident in wards without seclusion units. Ease of access to psychiatric intensive care units makes little difference to restraint thresholds or judgements of containment acceptability.

One-year incidence and prevalence of seclusion: Dutch findings in an international perspective

BACKGROUND

The Netherlands started a nationwide coercion reduction program in 2007. In 2011, accurate registration of coercive measures became obligatory by law.

OBJECTIVE

The aim of this study was to compare number and duration of coercive measures in the Netherlands with international data.

METHODS

2011 data on coercive measures were collected, using a system developed in Germany. To understand determinants of coercion, multilevel logistic regression was performed.

RESULTS

12.0 % (n = 5169) of patients (n = 42.960) in 2011 experienced at least one coercive measure. Exposure to coercion was comparable to other countries, and duration was higher. Medication use seemed to half average times in seclusion. In the Netherlands, coercion mainly constituted of seclusion and occurred in bipolar and psychotic disorders. In Germany, coercion was mostly mechanical restraint and occurred in organic disorders and schizophrenia.

CONCLUSIONS

Gathering comprehensive data allows comparisons between countries, increasing our understanding of the impact of different cultures, legislation and health care systems on coercion. In the Netherlands, seclusion is still the main type of coercion, despite significant improvements in the last few years. It is shorter when applied in combination with enforced medication.

Nursing interventions for substance use during psychiatric hospital admissions: Clinical context and predictors

Empirical information about how nurses manage substance use on psychiatric wards is lacking. The aims of the study were to identify the frequency and clinical features of incidents among a sample of inpatients over a 12-month period and how nursing staff intervened. Electronic, anonymized inpatient records were searched for incidents of substance use on 17 acute psychiatric wards in four hospitals in London. Searches were conducted for all patients admitted during 2012 and details of incidents and patient characteristics were extracted for analysis. Substance use was reported for 291 patients, with 25 incidents per 100 patients admitted to hospital. Only half of the incidents were followed by a response that specifically addressed the patients' substance use behaviour. These interactions usually concerned the circumstances and reasons for use, but rarely involved specific support for patients' substance use problems. The likelihood of staff taking any form of action was increased if the patient had been formally admitted, and was reduced if the patient was subject to containment during the shift or had a history of self-harm. The results demonstrate that nurses require specific training and guidance on supporting substance using patients.

Substance use and violence among psychiatric inpatients

Nursing staff on psychiatric wards often attribute patient violence and aggression to substance use. This study examined incidents of alcohol and illicit drug use among acute psychiatric inpatients and associations between substance use and violence or other forms of aggression. A sample of 522 adult psychiatric inpatients was recruited from 84 acute psychiatric wards in England. Data were collected from nursing and medical records for the first 2 weeks of admission. Only a small proportion of the sample was reported to have used or been under the influence of alcohol (5%) or drugs (3%). There was no physical violence during a shift when a patient had used alcohol or drugs. Substance using patients were also no more likely than others to behave violently at any point during the study period. However, incidents of substance use were sometimes followed by verbal aggression. Beliefs that substance using patients are likely to be violent were not supported by this study, and could impact negatively on therapeutic relationships between nurses and this patient group. Future studies are needed to examine how staff intervene and interact with intoxicated patients.

Safewards: the empirical basis of the model and a critical appraisal

ACCESSIBLE SUMMARY

In the previous paper we described a model explaining differences in rates of conflict and containment between wards, grouping causal factors into six domains: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. This paper reviews and evaluates the evidence for the model from previously published research. The model is supported, but the evidence is not very strong. More research using more rigorous methods is required in order to confirm or improve this model.

ABSTRACT

In a previous paper, we described a proposed model explaining differences in rates of conflict (aggression, absconding, self-harm, etc.) and containment (seclusion, special observation, manual restraint, etc.). The Safewards Model identified six originating domains as sources of conflict and containment: the patient community, patient characteristics, the regulatory framework, the staff team, the physical environment, and outside hospital. In this paper, we assemble the evidence underpinning the inclusion of these six domains, drawing upon a wide ranging review of the literature across all conflict and containment items; our own programme of research; and reasoned thinking. There is good evidence that the six domains are important in conflict and containment generation. Specific claims about single items within those domains are more difficult to support with convincing evidence, although the weight of evidence does vary between items and between different types of conflict behaviour or containment method. The Safewards Model is supported by the evidence, but that evidence is not particularly strong. There is a dearth of rigorous outcome studies and trials in this area, and an excess of descriptive studies. The model allows the generation of a number of different interventions in order to reduce rates of conflict and containment, and properly conducted trials are now needed to test its validity.

Influence of patient characteristics on duration of seclusion/restrain in acute psychiatric settings in Japan

AIM

The aim of this study was to investigate the current state of duration of seclusion/restraint in acute psychiatric settings in Japan and the effect of patient characteristics on duration of seclusion/restraint.

METHODS

During an 8-month period starting from November 2008, duration of seclusion/restraint and patient characteristics were investigated in 694 psychiatric inpatients who experienced seclusion/restraint in three emergency and three acute wards at four psychiatric hospitals. Reasons for starting seclusion/restraint were also assessed. Analysis was performed using generalized linear models, with the duration of seclusion/restraint as the dependent variable and patient characteristics and reasons for starting seclusion/restraint as independent variables.

RESULTS

Of the patients secluded/restrained, 58.6% had a primary diagnosis of schizophrenia (F20-F29) and a large proportion (37.9%) were secluded/restrained due to hurting others. Median hours ofseclusion/restraint were 204 and 82 h, respectively. The duration of seclusion was longer for patients with F20-F29 than those with disorders due to psychoactive substance use (F10-F19) or other diagnoses (F40-F99), and when the reason was danger of hurting others. In contrast, the duration of restraint in female patients and in patients with F10-F19 diagnosis was shorter.

CONCLUSION

The duration of seclusion/restraint at acute psychiatric care wards in Japan are much longer than those reported by previous overseas studies. Although Japanese structure issues such as more patients per ward and a lower ratio of nurses need to be considered, skills for dealing with patients with primary diagnosis of F20-F29 secluded due to danger posed to others should be improved.

Identification of the "minimal triangle" and other common event-to-event transitions in conflict and containment incidents

Although individual conflict and containment events among acute psychiatric inpatients have been studied in some detail, the relationship of these events to each other has not. In particular, little is known about the temporal order of events for individual patients. This study aimed to identify the most common pathways from event to event. A sample of 522 patients was recruited from 84 acute psychiatric wards in 31 hospital locations in London and the surrounding areas during 2009-2010. Data on the order of conflict and containment events were collected for the first two weeks of admission from patients' case notes. Event-to-event transitions were tabulated and depicted diagrammatically. Event types were tested for their most common temporal placing in sequences of events. Most conflict and containment occurs within and between events of the minimal triangle (verbal aggression, de-escalation, and PRN medication), and the majority of these event sequences conclude in no further events; a minority transition to other, more severe, events. Verbal abuse and medication refusal were more likely to start sequences of disturbed behaviour. Training in the prevention and management of violence needs to acknowledge that a gradual escalation of patient behaviour does not always occur. Verbal aggression is a critical initiator of conflict events, and requires more detailed and sustained research on optimal management and prevention strategies. Similar research is required into medication refusal by inpatients.

Improving seclusion practice: implications of a review of staff and patient views

This review explores patient and staff perceptions and improvement suggestions regarding seclusion in psychiatric inpatient settings. After an extensive literature search, 39 empirical papers were included in the review. According to the literature, patients perceived seclusion to be a distinct negative incident. Staff thought seclusion had a therapeutic effect and believed that units could not operate effectively without seclusion, but regretted that the situation was not resolved differently. Staff and patients had suggestions to improve the seclusion experience. Common themes in relation to the implications for practice are the need for better communication and more contact between patients and staff before, during and after the seclusion event.

Differences in seclusion rates between admission wards: does patient compilation explain?

Comparison of seclusion figures between wards in Dutch psychiatric hospitals showed substantial differences in number and duration of seclusions. In the opinion of nurses and ward managers, these differences may predominantly be explained by differences in patient characteristics, as these are expected to have a large impact on these seclusion rates. Nurses assume more admissions of severely ill patients are related to higher seclusion rates. In order to test this hypothesis, we investigated differences in patient and background characteristics of 718 secluded patients over 5,097 admissions on 29 different admission wards over seven Dutch psychiatric hospitals. We performed an extreme group analysis to explore the relationship between patient and ward characteristics and the wards' number of seclusion hours per 1,000 admission hours. In a multivariate and a multilevel analysis, various characteristics turned out to be related to the number of seclusion hours per 1,000 admission hours as well as to the likelihood of a patient being secluded, confirming the nurses assumptions. The extreme group analysis showed that seclusion rates depended on both patient and ward characteristics. A multivariate and multilevel analyses revealed that differences in seclusion hours between wards could partially be explained by ward size next to patient characteristics. However, the largest deal of the difference between wards in seclusion rates could not be explained by characteristics measured in this study. We concluded ward policy and adequate staffing may, in particular on smaller wards, be key issues in reduction of seclusion.

Reducing seclusion through involuntary medication: a randomized clinical trial

The study evaluated whether seclusion and coercive incidents would be reduced in extent and number if involuntary medication was the first choice of intervention. Patients admitted to an acute psychiatric ward were randomly allocated to two groups. In Group 1, involuntary medication was the intervention of first choice for dealing with agitation and risk of violence. In Group 2, seclusion was the intervention of first choice. Patients' characteristics between the groups were compared by Pearson χ(2) and two-sample t-tests; the incidence rates and risk ratios (RRs) were calculated to examine differences in number and duration of coercive incidents. In Group 1, the relative risk of being secluded was lower than in Group 2, whereas the risk of receiving involuntary medication was higher. However, the mean duration of the seclusion incidents did not differ significantly between the two groups; neither did the total number of coercive incidents. Although the use of involuntary medication could successfully replace and reduce the number of seclusions, alternative interventions are needed to reduce the overall number and duration of coercive incidents. A new policy for managing acute aggression - such as involuntary medication - can be implemented effectively only if certain conditions are met.

Early detection of risk factors for seclusion and restraint: a prospective study

AIM

The study aims to examine the predictive power of static and dynamic risk factors assessed at admission to an acute psychiatric ward and to develop a prediction model evaluating the risk of seclusion and restraint.

METHODS

Over 20 months, data on demographic and clinical characteristics, psychosocial functioning, level of insight, uncooperativeness, and use of coercive measures were collected prospectively on 520 patients at admission. Logistic regression analysis was used to develop a prediction model. The magnitude of the predictive power of this model was estimated using receiver operating characteristic analysis.

RESULTS

The prediction model contained one static predictor (involuntary commitment) and two dynamic predictors (psychological impairment and uncooperativeness), with a high predictive power (receiver operating characteristic area under the curve = 0.83). The final risk model classified 72% of the patients correctly, with a higher sensitivity rate (80%) than specificity rate (71%).

CONCLUSION

Early assessment of patients' psychological impairment and uncooperativeness can help clinicians to recognize patients at risk for coercive measures and approach them on time with preventive and less restrictive interventions. Although this simple, highly predictive model accurately predicts the risk of seclusion or restraint, further validation studies are needed before it can be adopted into routine clinical practice.

Investigation into the acceptability of door locking to staff, patients, and visitors on acute psychiatric wards

There is disagreement among psychiatric professionals about whether the doors of acute psychiatric wards should be kept locked to prevent patients from leaving and harming themselves or others. This study explored patient, staff, and visitor perceptions about the acceptability of locking the ward door on acute psychiatric inpatient wards. Interviews were conducted with 14 registered nurses, 15 patients, and six visitors from three different acute wards. Findings revealed commonalities across all groups, with general agreement that locking the door reduced absconding. Staff expressed feelings of guilt, embarrassment, and fear of being blamed when a patient absconded. Staff also reported that open wards created anxious vigilance to prevent an abscond and increased workload in allocating staff to watch the door, whereas staff on partially-locked doors also perceived an increased workload in letting people in and out of the ward. Patients had mixed feelings about the status of the door, expressing depression, a sense of stigma, and low self-esteem when the door was locked. The issue of balancing safety and security on acute psychiatric wards against the autonomy of patients is not easily resolved, and requires focused research to develop innovative nursing practices.

Under the gaze of staff: special observation as surveillance

PURPOSE

This study explores the relationship of special observation (SO) to a range of patient, staff, and ward variables.

DESIGN AND METHODS

End-of-shift reports were completed by nurses on 136 acute mental health wards in England during 2004 and 2005.

FINDINGS

Intermittent SO (patient checked at specified intervals) was used five times more frequently than constant SO (patient kept within sight or reach). Significant relationships were found between SO and measures of ward surveillance, door locking, and the ease of observing patients on the wards. Both types of SO were more common when higher numbers of staff without a nursing qualification were on duty.

PRACTICE IMPLICATIONS

Improved ward design, less reliance on unqualified staff, and greater use of surveillance measures may reduce the need for SO.