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

A Scoping Review on Staff Attitudes towards the Use of Coercion in Mental Healthcare

Attitudes of mental health professionals towards the use of coercion are highly relevant concerning its use coercion in mental healthcare, as mental health professionals have to weigh ethical arguments and decide within a legal frame in which situations to use coercion or not. Therefore, assessment of those attitudes is relevant for research in this field. A vital instrument to measure those attitudes towards the use of coercion is the Staff Attitude to Coercion Scale. This scoping review aims to provide a structured overview of the advantages and limitations in the assessment of attitudes toward coercion. We conducted a scoping review in Medline, PsycINFO, CINAHL, and Web of Science, based on the PRISMA-ScR. Inclusion criteria were empirical studies on the attitudes of mental health professionals. We included 80 studies and systematically mapped data about the main results and limitations in assessing attitudes toward coercion. The main results highlighted the relevance and increased interest in staff attitudes towards coercion in mental healthcare. Still, the majority of the included studies relied on a variety of different concepts and definitions concerning attitudes. The data further indicated difficulties in developing new and adapting existing assessment instruments because of the equivocal definitions of underlying concepts. To improve the research and knowledge in this area, future studies should be based on solid theoretical foundations. We identified the need for methodological changes and standardized procedures that take into account existing evidence from attitude research in social psychology, nursing science, and other relevant research fields. This would include an update of the Staff Attitude to Coercion Scale based on the limitations identified in this review.

[Isolation and mechanical restraint in psychiatry]

Since 2016, there has been a succession of legal texts aimed at framing the use of seclusion and mechanical restraint in psychiatric services. These legal evolutions are not without consequence on the practice of caregivers. We propose here a practical summary of this issue.

A Cross-Sectional Study to Assess the Frequency of Restraint, and Knowledge and Attitudes of the Caregivers of Patients Toward Restraint in a General Hospital Psychiatry Setting from South India

Background

There is limited Indian data on the epidemiology of hospital-based restraint practices and the knowledge and attitude of caregivers toward restraint. Therefore, this study aimed to report the frequency and pattern of restraints in a general hospital psychiatry setting and assess the knowledge and attitude about restraint practices among caregivers of patients.

Methods

We calculated the frequency of restraints (physical and chemical) over one year. The knowledge and attitude toward restraint were assessed in 75 caregivers each of patients from inpatient and outpatient settings, using a questionnaire designed by the authors and pretested in a pilot study.

Results

The frequency of any form of restraint was 19%. The frequency of chemical and physical restraints was 19% and 0.5%, respectively. Less than 20% of caregivers in both groups reported that restraint was either stigmatizing (5.33% inpatient caregivers vs. 12% outpatient caregivers), cruel (8% inpatient caregivers vs. 15.33% outpatient caregivers), or a measure of punishment (9% inpatient caregivers vs. 16% outpatient caregivers). No significant difference was found between knowledge and attitude about restraint between caregivers of outpatients and inpatients, except for a significantly greater number of caregivers of outpatients reporting that the restraint practices in the hospital were similar to those adopted by faith healers or religious/spiritual centers.

Conclusion

The frequency of either physical or chemical restraint was less compared to the existing international and Indian data. In addition, most caregivers of patients of both outpatients and inpatients did not report a negative attitude toward restraints.

Acknowledging caregivers' vulnerability in the managment of challenging behaviours to reduce control measures in psychiatry

BACKGROUND

The management of challenging behaviours in inpatient with intellectual disability and/or autism spectrum disorders can lead to an escalation of control measures. In these complex situations where patients have an intellectual disability/autism spectrum disorder accompanied by a psychiatric comorbidity, the experiences of caregivers related to the crisis management have rarely been studied.

PURPOSE

This study examined the moral experiences of caregivers related to challenging behaviours' management and alternatives to control measures.

RESEARCH DESIGN

Using Charles Taylor's hermeneutic framework, a 2-month focused ethnography with a participatory approach was used.

PARTICIPANTS AND RESEARCH CONTEXT

Sixteen caregivers were interviewed in a Canadian mental health setting for adults with intellectual disability/autism spectrum disorder and psychiatric comorbidity.

ETHICAL CONSIDERATIONS

The research was conducted in compliance with the Declaration of Helsinki and local Research Ethics Board approval. Written informed consent was collected systematically from participants.

FINDINGS

By accounting for caregivers' moral experiences, this study sheds light on a neglected dimension of the care relationship: the vulnerability of the caregiver. We highlight the main barriers and facilitators to alternatives to control measures. First, a caregiver's vulnerability was characterised by the overall impact of challenging behaviours and the moral distress associated with the use of control measures and exclusion mechanisms of intellectual disability/autism spectrum disorder patients. Second, a strong ambiguity between care and control measures and a lack of inclusive approaches were identified as the two main barriers to challenging behaviour management. Third, the involvement, both professional and personal, of caregivers was deemed necessary to implement alternatives to control measures.

DISCUSSION

A conflict of values opposes two conceptions of autonomy: a rational autonomy, which is counterproductive to the reduction of control measures, versus a relational autonomy based on shared vulnerability.

CONCLUSION

The recognition of caregiver's vulnerability is a benchmark to create alternative approaches, which defuse the logic of control and promote an ethics of care within which caregivers' self-concern can be understood as fostering mutual respect.

[Freedom and constraint of the ambulatory patient]

The use of physical, as well as chemical, restraints is subject to a medical prescription. It is a medical decision, most often fortunately made as a team. Responsibilities are involved when it is implemented. It is necessary to know them, as well as it is essential to know the alternatives. A study of the caring perception of restraint of hospitalized patients with neurocognitive disorders and excessive ambulation has been carried out. Thus, an ethical approach would make it possible to adopt a fairer approach taking into account the notions of individual and collective freedom, safety and risk.

Intégration des droits humains dans la pratique du personnel infirmier faisant usage de coercition en santé mentale : recension systématique des écrits et méta-ethnographie

Introduction and background : The last decade has seen a steady and rising use of coercion in mental health care, as well as an increase in the number of forms it takes. The application of these measures frequently relies on the work of nurses, but few studies have analyzed the human rights issues raised by these practices.Aim : To produce a qualitative synthesis of how human rights are integrated into the practice of nurses who use coercion in mental health care.Methodology : A systematic review of qualitative scientific literature published between 2008 and 2018 was conducted and supplemented by a meta-ethnographic analysis.Results : The analysis of the forty-six selected studies revealed four distinct themes : coercion in mental health care as a socio-legal object, issues of recognition of human rights in mental health care, role conflict experienced by nurses, and the conceptualization of coercion as a necessary evil or a critical incident.Discussion and conclusion : Further research is needed to understand the specifics of the continuum of support and control that characterizes the coercive work of psychiatric nurses.

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.

[Attitude of psychiatrists and psychiatry residents in Lebanon towards restraint and informed consent]

OBJECTIVES

Psychiatry differs from the rest of medical specialties by the unique character of its pathologies, which makes ethical reflection difficult, including the collection of informed consent and the use of restraint and the seclusion-room. This reflection can be affected by subjectivity and a variety of influences, hence the interest of studying the attitude of psychiatrists and residents in psychiatry in Lebanon with regard to restraint and informed consent.

METHODS

We collected data using an anonymous questionnaire that we sent as a Google form to Lebanese psychiatrists and psychiatry residents by email and phone messages. The descriptive analysis was done using Microsoft Excel software, and the analytical analysis was done using the SPSS software and the following statistical tests: independent-sample test and the Mann Whitney U test.

RESULTS

Forty people responded, including 19 men and 21 women (16 psychiatric interns, 15 university psychiatrists and 9 non-university psychiatrists). Concerning the questions related to the use of restraint, 70% did not find that it is being commonly used in hospital practice. However, 92.5% would use it to counter the patient's dangerousness and 60% to help deliver treatment. 57.5% did not find the repeated usage of restraint as a dehumanization of care, but the majority (70%) agreed with the need for temporal limitation of any form of restraint. As for the ability to consent, 90% considered a patient in a psychotic state as unfit to consent.

CONCLUSIONS

Restraint is considered uncommon by psychiatrists and psychiatric residents in Lebanon and must remain an option of last resort with efforts being made upstream in order to avoid situations where the use of restraint becomes mandatory. Post critical thinking is paramount, and restraint should never respond to a lack of manpower or a security goal. Informed consent is one of the most important guarantors of the principle of autonomy, and must be sought in each patient, individually. Finally, no significant difference was found between the subgroups, which would therefore become a single population. Ethical reflection would therefore be directly linked to the population. Mental illnesses are becoming more common and an important source of morbidity worldwide. It is our role to ensure the dignity of the mentally ill. The introduction of the Psychiatric Nurse Diploma, an increase in the relational approach to the training of psychiatrists in Lebanon, and an increase in the number of health care teams may help to maximize the ability of capacity.

[Patients assaulted in psychiatric institutions: Literature review and clinical implications]

BACKGROUND

The psychiatric ward is a place where all forms of violence are treated. Occasionally, this violence involves acts of aggression between patients in emergency psychiatric units or hospital wards. Such events can lead to the development or worsening of posttraumatic stress disorder.

METHODS

To establish the context, we first examined the epidemiology data concerning posttraumatic stress disorder in psychiatric patients who were frequently exposed to assaults. Secondly, we examined the issue of sexual and physical assaults between patients receiving treatment in a psychiatric ward. In this context, we studied possible occurrence of posttraumatic stress disorder associated with exposure to assaults of this kind.

RESULTS

In certain cases, potentially traumatic exposure to violence was unknown to the medical staff or not taken into consideration. This would induce a risk of later development of posttraumatic stress disorder that would not be treated during the stay in psychiatry.

CONCLUSION

To date, few scientific studies have focused on the proportion of patients assaulted by other patients during treatment in a psychiatric ward and the subsequent development of peritraumatic reactions and/or posttraumatic stress disorder associated with these assaults. We know that an insufficient number of public and private health institutions report the existence of such facts to the competent authorities. Also, a minority of clinicians and caregivers are trained in screening and management of trauma victims. Yet, these issues are particularly relevant in the scope of public health and health promotion.