Determinants of seclusion after aggression in psychiatric inpatients

An Evaluation of the Implementation of a "No Force First" Informed Organisational Guide to Reduce Physical Restraint in Mental Health and Learning Disability Inpatient Settings in the UK

BACKGROUND

The use of physical restraint on vulnerable people with learning disabilities and mental health problems is one of the most controversial and criticised forms of restrictive practice. This paper reports on the implementation of an organisational approach called "No Force First" within a large mental health organisation in England, UK. The aim was to investigate changes in violence/aggression, harm, and physical restraint following implementation.

METHODS

The study used a pretest-posttest quasi-experimental design. Recorded incidents of violence/aggression from 44 inpatient mental health and learning disabilities (including forensic) wards were included (n = 13,599). Two study groups were created for comparison: the "intervention" group comprising all incidents on these wards during the 24 months post-implementation (2018-2019) (n = 6,551) and the "control" group comprising all incidents in the 24 months preceding implementation (2015-2016) (n = 7,048). Incidents recorded during implementation (i.e., 2017) were excluded (n = 3,705). Incidence rate ratios (IRR) were calculated with 95% confidence intervals (95% CI). Multivariate regression models using generalised estimating equations were performed to estimate unadjusted and adjusted prevalence ratios (aPR) of physical restraint and harm, using type of wards, incident, and violence/aggression as key covariates.

RESULTS

A significant 17% reduction in incidence of physical restraint was observed [IRR = 0.83, 95% CI 0.77-0.88, p < 0.0001]. Significant reductions in rates of harm sustained and aggression/violence were also observed, but not concerning the use of medication during restraint. The prevalence of physical restraint was significantly higher in inpatients on forensic learning disability wards than those on forensic mental health wards both pre- (aPR = 4.26, 95% CI 2.91-6.23) and post-intervention (aPR = 9.09, 95% CI 5.09-16.23), when controlling for type of incident and type of violence/aggression. Physical assault was a significantly more prevalent risk factor of restraint use than other forms of violence/aggression, especially that directed to staff (not to other patients).

CONCLUSIONS

This is a key study reporting the positive impact that organisational models and guides such as "No Force First" can have on equipping staff to focus more on primary and secondary prevention as opposed to tertiary coercive practices such as restraint in mental health and learning disabilities settings.

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.

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.

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.

Predicting inpatient aggression by self-reported impulsivity in forensic psychiatric patients

BACKGROUND

Empirical knowledge of 'predictors' of physical inpatient aggression may provide staff with tools to prevent aggression or minimise its consequences.

AIM

To test the value of a self-reported measure of impulsivity for predicting inpatient aggression.

METHODS

Self-report measures of different domains of impulsivity were obtained using the Urgency, Premeditation, Perseverance, Sensation seeking, Positive urgency (UPPS-P) impulsive behaviour scale with all 74 forensic psychiatric inpatients in one low-security forensic hospital. Aggressive incidents were measured using the Social Dysfunction and Aggression Scale (SDAS). The relationship between UPPS-P subscales and the number of weeks in which violent behaviour was observed was investigated by Poisson regression.

RESULTS

The impulsivity domain labelled 'negative urgency' (NU), in combination with having a personality disorder, predicted the number of weeks in which physical aggression was observed by psychiatric nurses. NU also predicted physical aggression within the first 12 weeks of admission.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The results indicate that NU, which represents a patient's inability to cope with rejection, disappointments or other undesired feelings, is associated with a higher likelihood of becoming violent while an inpatient. This specific coping deficit should perhaps be targeted more intensively in therapy. Self-reported NU may also serve as a useful adjunct to other risk assessment tools and as an indicator of change in violence risk. Copyright © 2015 John Wiley & Sons, Ltd.

Age structure at diagnosis affects aggression in a psychiatric inpatient population: age structure affecting inpatient aggression

Study of inpatient aggression in psychiatric inpatient units (PIUs), where vulnerable patients interact intensely in small groups, is hampered by a lack of systematic monitoring of aggressive events in the context of group dynamics. Our current study examines the relationship between aggression and group structure in the PIU of a general tertiary-care hospital over a 9-month period. The severity of aggression was monitored daily using the Overt Aggression Scale (OAS). Clinical data including the daily number and mean age of subpopulations with different diagnoses were acquired. Cross-correlation function and autoregressive integrated moving average modeling were used to assess the effects of various group structure parameters on the incidence of aggressive events in the PIU. The daily total OAS score correlated positively with the daily mean age of patients with schizophrenia and bipolar disorder. By contrast, the OAS total score demonstrated a negative correlation with the daily mean age of patients with major depression. The age of the patients at diagnosis is an important group structure that affects the incidence of aggression in a PIU.

Association between short-term structured risk assessment outcomes and seclusion

Research findings indicate that the symptoms and behaviour of acute psychiatric patients can fluctuate drastically within hours, and that structured daily risk assessments can reduce the risk of aggressive incidents and the duration of seclusion. The aim of this study was to investigate the validity of two structured observation tools, the Brøset Violence Checklist (BVC) and the Kennedy Axis V), as an aid in seclusion-related clinical decision-making. In this study, 7403 day-to-day risk assessments were collected over 10 725 admission days (72% of the maximum number of structured assessments). A total of 7055 daily assessment scores from 301 acute psychiatric patients were used for the multilevel analysis. The sample demonstrated that dynamic and static factors were related to seclusion. Dynamic factors included dysfunctional scores on the item 'confusion' of the Brøset Violence Checklist, and psychological impairment and impairment of social skills on the Kennedy Axis V. Static factors included non-Western descent, male sex, age less than 35 years, unmarried, and to some extent, a personality disorder. McFadden's pseudo R(2) value showed that most of the final model was related to the dynamic factors. We concluded that the incorporation of the BVC and the Kennedy Axis V into standard practice was helpful in identifying patients at high risk of seclusion.