Methodological issues in monitoring the use of coercive measures

Rates and risk factors of coercive measure use in inpatient child and adolescent mental health services: a systematic review and narrative synthesis

Reducing the use of coercive measures in inpatient child and adolescent mental health services (CAMHS) requires an understanding of current rates and associated factors. We conducted a systematic review of research published between Jan 1, 2010, and Jan 10, 2024, addressing rates and risk factors for mechanical, physical, or pharmacological restraint, seclusion, or forced tube feeding in inpatient CAMHS. We identified 30 studies (including 39 027 patients or admissions) with low risk of bias. Median prevalence was 17·5% for any coercive measure, 27·7% for any restraint, and 6·0% for seclusion. Younger age, male sex, ethnicity or race other than White, longer stay, and repeated admissions were frequently linked to coercive measure use. Variable rates and conflicting risk factors suggest that patient traits alone are unlikely to determine coercive measure use. More research, especially in the form of nationwide studies, is needed to elucidate the impact of care and staff factors. Finally, we propose reporting guidelines to improve comparisons over time and settings.

A comprehensive examination of research instruments utilized for assessing the attitudes of healthcare professionals towards the use of restraints in mental healthcare: A systematic review

AIM

This systematic review aimed to identify, describe and evaluate questionnaires measuring health professionals' attitudes towards restraints in mental healthcare.

DESIGN

A systematic review was undertaken in accordance with the COSMIN protocol for systematic review and the relevant sections of the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

DATA SOURCES

OVID Medline, OVID nursing, Psychinfo, Embase and Cinahl were systematically searched from databases inception, with an initial search in December 2021 and updated in April 2022.

REVIEW METHODS

The inclusion criteria compromised articles reporting on self-reported instruments of attitudes or perceptions, development or validation of instruments and the evaluation of one or more measurement properties. Articles using multiple instruments in one study or not published in English were excluded. Two researchers independently extracted the data and appraised the methodological quality using the COSMIN guidelines and standards (consensus-based standards for the selection of health measurement instrument). A narrative synthesis without meta-analysis was performed. The systematic review was registered in PROSPERO Protocol ID CRD42022308818.

RESULTS

A total of 23 studies reporting ten instruments were included. The findings revealed a broad variation in the content of the questionnaires, the use of terms/constructs and the context in which the various instruments measure attitudes towards coercive measures. Many studies lacked sufficient details on report of psychometric properties. Finally, the results were not summarized and the evidence not GRADED.

CONCLUSIONS

There is a need for updated and adapted instruments with origins in theory and clear joint definitions such that attitudes towards coercive measures can be reliably assessed regarding the validity and reliability of instruments, which will be of importance to facilitate the use of instruments in research and clinical settings.

IMPACT

Reviews addressing surveys, self-reported attitudes towards restraints in mental healthcare and examination of psychometric properties seem limited. We highlight distinct complexity, psychometric limitations and broad variation in the context and content measuring attitudes towards coercive measures, and their various use of terms/constructs in the existing questionnaires. These findings contribute to further research regarding the development of questionnaires and the need of representing the concept well - carefully denoted by the indicators, likewise the importance of applying questionnaires with properly reported measurement properties in terms of validity and reliability to ensure the use in research and clinical settings.

Expert opinions on improving coercion data collection across Europe: a concept mapping study

Introduction

Coercion is frequently used in mental health practice. Since it overrides some patients' fundamental human rights, adequate use of coercion requires legal and ethical justifications. Having internationally standardised datasets to benchmark and monitor coercion reduction programs is desirable. However, only a few countries have specific, open, publicly accessible registries for this issue.

Methods

This study aims to assemble expert opinions regarding strategies that might be feasible for promoting, developing, and implementing an integrated and differentiated coercion data collection system in Europe at national and international levels. A concept mapping methodology was followed, involving 59 experts from 27 countries in generating, sorting and rating strategies regarding relevance and feasibility. The experts were all researchers and/or practitioner members of an EU-COST-Action focused on coercion reduction Fostering and Strengthening Approaches to Reducing Coercion in European Mental Health Services (FOSTREN).

Results

A hierarchical cluster analysis revealed a conceptual map of 41 strategies organized in seven clusters. These clusters fit into two higher-order domains: "Advancing Global Health Research: Collaboration, Accessibility, and Technological Innovations/Advancing International Research" and "Strategies for Comprehensive Healthcare Data Integration, Standardization, and Collaboration." Regarding the action with the higher priority, relevance was generally rated higher than feasibility. No differences could be found regarding the two domains regarding the relevance rating or feasibility of the respective strategies in those domains. The following strategies were rated as most relevant: "Collection of reliable data", "Implementation of nationwide register, including data on coercive measures", and "Equal understanding of different coercive measures". In analysing the differences in strategies between countries and their health prosperity, the overall rating did not differ substantially between the groups.

Conclusion

The strategy rated as most relevant was the collection of reliable data in the nationwide health register, ensuring that countries share a standard understanding/definition of different coercive measures. Respondents did not consider the feasibility of establishing a shared European database for coercive measures to be high, nor did they envision the unification of mental health legislation in the future. There is some consensus on the most suitable strategies that can be adopted to enable international benchmarking of coercion in mental health settings.

Risk assessment for aggressive behaviour in schizophrenia

BACKGROUND

Aggressive or violent behaviour is often associated with people with schizophrenia in common perceptions of the disease. Risk assessment methods have been used to identify and evaluate the behaviour of those individuals who are at the greatest risk of perpetrating aggression or violence or characterise the likelihood to commit acts. Although many different interventions have been developed to decrease aggressive or violent incidences in inpatient care, staff working in inpatient settings seek easy-to-use methods to decrease patient aggressive events. However, many of these are time-consuming, and they require intensive training for staff and patient monitoring. It has also been recognised in clinical practice that if staff monitor patients' behaviour in a structured manner, the monitoring itself may result in a reduction of aggressive/violent behaviour and incidents in psychiatric settings.

OBJECTIVES

To assess the effects of structured aggression or violence risk assessment methods for people with schizophrenia or schizophrenia-like illnesses.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ISRCTN registry, ClinicalTrials.gov, and WHO ICTRP, on 10 February 2021. We also inspected references of all identified studies.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing structured risk assessment methods added to standard professional care with standard professional care for the evaluation of aggressive or violent behaviour among people with schizophrenia.

DATA COLLECTION AND ANALYSIS

At least two review authors independently inspected citations, selected studies, extracted data, and appraised study quality. For binary outcomes, we calculated a standard estimation of the risk ratio (RR) and its 95% confidence interval (CI). For continuous outcomes, we calculated the mean difference (MD) and its 95% CI. We assessed risk of bias in the included studies and created a summary of findings table using the GRADE approach.

MAIN RESULTS

We included four studies in the review. The total number of participants was not identifiable, as some studies provided number of participants included, and some only patient days. The studies compared a package of structured assessment methods with a control group that included routine nursing care and drug therapy or unstructured psychiatric observations/treatment based on clinical judgement. In two studies, information about treatment in control care was not available. One study reported results for our primary outcome, clinically important change in aggressive/violent behaviour, measured by the rate of severe aggression events. There was likely a positive effect favouring structured risk assessment over standard professional care (RR 0.59, 95% CI 0.41 to 0.85; 1 RCT; 1852 participants; corrected for cluster design: RR 0.59, 95% CI 0.37 to 0.93; moderate-certainty evidence). One trial reported data for the use of coercive measures (seclusion room). Compared to standard professional care, structured risk assessment may have little or no effect on use of seclusion room as days (corrected for cluster design: RR 0.92, 95% CI 0.27 to 3.07; N = 20; low-certainty evidence) or use of seclusion room as secluded participants (RR 1.83, 95% CI 0.39 to 8.7; 1 RCT; N = 20; low-certainty evidence). However, seclusion room may be used less frequently in the standard professional care group compared to the structured risk assessment group (incidence) (corrected for cluster design: RR 1.63, 95% CI 0.49 to 5.47; 1 RCT; N = 20; substantial heterogeneity, Chi2 = 0.0; df = 0.0; P = 0.0; I2 = 100%; low-certainty evidence). There was no evidence of a clear effect on adverse events of escape (RR 0.2, 95% CI 0.01 to 4.11; 1 RCT; n = 200; very low-certainty evidence); fall down (RR 0.33, 95% CI 0.04 to 3.15; 1 RCT; n = 200; very low-certainty evidence); or choking (RR 0.2, 95% CI 0.01 to 4.11; 1 RCT; n = 200; very low-certainty evidence) when comparing structured risk assessment to standard professional care. There were no useable data for patient-related outcomes such as global state, acceptance of treatment, satisfaction with treatment, quality of life, service use, or costs.

AUTHORS' CONCLUSIONS

Based on the available evidence, it is not possible to conclude that structured aggression or violence risk assessment methods are effective for people with schizophrenia or schizophrenia-like illnesses. Future work should combine the use of interventions and structured risk assessment methods to prevent aggressive incidents in psychiatric inpatient settings.

Dual harm: Violent behaviour to others and self-harm behaviour in adults compulsorily admitted to a Dutch psychiatric hospital

BACKGROUND

Verbal and physical violence in psychiatric hospitals can have harmful consequences for staff members, such as physical injury, traumatisation, and sick leave, and they often accompany involuntary admission. Harm to others may co-occur with self-harm, i.e., dual harm. However, little is known about the association between dual-harm and violent behaviour towards staff members and its clinical outcomes, such as seclusion and rapid tranquilisation after involuntary admission to a psychiatric inpatient unit.

METHOD

A convenience sample of patients admitted involuntarily (N = 384; mean age = 48.03, SD = 19.92) between January 2016 and December 2019 in Western Brabant, the Netherlands, was used to design a retrospective file audit. Distinct harm groups, marked by the presence/absence of self- and/or other-harm, were investigated using multivariate linear regression modelling on the seriousness of violent acts and the total length of admission. Logistic regression analyses were used to study the association between harm groups and the administration of rapid tranquilisation, seclusion, and extended involuntary admissions.

RESULTS

Several harm groups were identified, including self-harm only, other-harm only, and dual-harm groups. Psychiatric patients admitted to the hospital because of (the risk of) violence towards others had a higher risk of violent incidents during admission and some restrictive measures. In a subgroup of patients with psychotic disorders, patients with dual harm committed the most serious violent incidents compared to those in the other harm groups.

CONCLUSION

Distinct harm groups were identified in a sample of involuntarily admitted patients. In a general adult psychiatric setting, patients at risk for violent behaviour, especially dual-harm patients, should be identified and monitored as part of the risk assessment. Future research is needed to explore more clinical correlates in the proposed distinction between harmful groups and to assess long-term prognosis.

Treatment without consent in adult psychiatry inpatient units: a retrospective study on predictive factors

Background

Coercion is one of the most important challenges in mental health. In Switzerland, forced medication can be applied during an emergency (Art. 435 of the Civil Code) or over a longer period in case of endangerment of others or oneself (Art. 434). We aimed to analyze the predictors of this specific treatment without consent.

Methods

Forced medication prescriptions in the Division of Adult Psychiatry of the Geneva University Hospitals between 2018 and 2021 were retrospectively analyzed. Medication under Article 434 was the main outcome variable. Age, gender, admission mode, main diagnosis, and the Health of the Nation Outcome Scales (HoNOS) score at admission were considered as potential predictors. T-test and Pearson's chi-square test were used to compare continuous and categorical variables. A logistic regression was performed to find significant predictors of forced medication.

Results

Seventy-one out of 4,326 inpatients were subjected to forced medication under Art. 434. HoNOS global scores at admission were not significantly different in the forced medication group compared to the control group. Aggressive behavior was lower in the former at the univariate level. Forced medication was associated at the multivariate level with female gender, involuntary admission, and psychosis.

Conclusion

Women suffering from psychosis are more at risk of receiving involuntary and repeated medication. The risk of deterioration in psychosocial functioning or behavioral disorganization seems to be the main argument for this coercive measure. Future studies should focus on the patient's perception of this coercion to prevent it and improve adherence to care. Follow-up after discharge might be useful to evaluate a long-term benefit.

PROD-ALERT: Psychiatric restraint open data—analysis using logarithmic estimates on reporting trends

Aims and Methods

Restraint reporting varies, which undermines regulation, obfuscates analyses, and incentivises minimisation. The English Mental Health Units Use of Force Act 2018, “Seni's Law” mandates reporting. This paper analysed open data from all psychiatric and learning disability institutions in England from September 2020 to August 2021. We correlated logarithms of “people restrained per month”, against “bed days” per month and “people under legal mental health detention” per month, per institution. We designated institutions reporting some restraint for at least 11 of 12 months as reporting “completely” and used their trend to infer rates from non-“complete” institutions. Allowance was made for size. Our a priori manual can be shared on request.

Results

Logarithms of people restrained per month and bed-days per month correlated among complete reporters: R² 0.90 (2.s.f). Persons detained per month also correlated with restraint: R² 0.78. “Partial” institutions reported intermittently. “Joiner” institutions reported firstly null, then substantive reporting. “Null” institutions (including the largest) reported no restraint. Precisely-reporting institutions with high inverse variance between months reported similar restraint-rates but less-precise reported lower rates. In institutions reporting no restraint, two independent “true rate” estimations, by bed-days or people detained, correlated across institutions: R² 0.95. Inference from size suggested non-complete reporters restrained 1,774 people in England per month 95% CI (1,449–2,174).

Clinical implications

Restraint remains under-reported. Institutional size explains most restraint variation among complete reporting institutions, 90% of R². Institutional restraint reports can be compared per-bed per-month. Rates of people detained are a useful independent “checking” comparator in England.

The use of coercive measures in a high security setting in Belgium: Prevalence and risk factors

Coercive measures are often used in forensic psychiatric settings as a strategy to manage violent and other problematic behavior. Few studies have been published regarding the use of coercive measures in high security populations. This is the first empirical study on this subject in Belgium. The aim of the present study was to examine the prevalence rates of coercive measures in Flanders' two high security settings and to identify individual patient risk factors for being subjected to a coercive measure. The study included all patients (N = 654) who were admitted in the Forensic Psychiatric Centres of Antwerp or Ghent over a six-year period. Data on the use of coercive measures (seclusion, mechanical restraint, and chemical restraint) were registered prospectively. Several regression analyses were conducted with multiple independent variables. The results show that half of the population (50.3%) was subjected to at least one coercive measure during admission in one of the high security settings. A small subgroup of patients (6.4%) was the subject of half of all coercive measures (50,4%). Seclusion was the most frequently used coercive measure (48.3%), followed by chemical restraint (20.2%). The prevalence rate of mechanical restraint was very low (0.8%) compared to previous research in similar populations. Various individual risk factors were significantly associated with a higher use of coercive measures. Clinical implications are discussed and the importance of developing international standards on recording and reporting on coercive measures is highlighted.

"Disruptive Behavior" or "Expected Benefit" Are Rationales of Seclusion Without Prior Aggression

OBJECTIVE

In the Netherlands, seclusion of patients with a psychiatric disorder is a last-resort measure to be used only in the event of (imminent) severe danger or harm. Although aggressive behavior is often involved, seclusions not preceded by aggression also seem to occur. We sought insight into the non-aggressive reasons underlying seclusion and investigated the factors associated with it.

METHOD

We included all patients admitted to a Dutch psychiatric hospital in 2008 and 2009. Seclusions had been registered on Argus-forms, and aggression incidents had been registered on the Staff Observation Aggression Scale-Revised (SOAS-R), inspectorate forms and/or patient files. Determinants of seclusion with vs. without prior aggression were analyzed using logistic regression. Reasons for seclusion without prior aggression were evaluated qualitatively and grouped into main themes.

RESULTS

Of 1,106 admitted patients, 184 (17%) were secluded at some time during admission. Twenty-one (11.4%) were excluded because information on their seclusion was lacking. In 23 cases (14%), neither SOAS-R, inspectorate forms nor individual patient files indicated any aggression. Univariable and multivariable regression both showed seclusion without preceding aggression to be negatively associated with daytime and the first day of hospitalization. In other words, seclusion related to aggression occurred more on the first day, and during daytime, while seclusion for non-aggressive reasons occurred relatively more after the first day, and during nighttime. Our qualitative findings showed two main themes of non-aggressive reasons for seclusion: "disruptive behavior" and "beneficial to patient."

CONCLUSION

Awareness of the different reasons for seclusion may improve interventions on reducing its use. Thorough examination of different sources showed that few seclusions had not been preceded by aggression. The use of seclusion would be considerably reduced through interventions that prevent aggression or handle aggression incidents in other ways than seclusion. However, attention should also be paid to the remaining reasons for seclusion, such as handling disruptive behavior and focusing on the beneficial effects of reduced stimuli. Future research on interventions to reduce the use of seclusion should not only aim to reduce seclusion but should also establish whether seclusions preceded by aggression decrease different from seclusions that are not preceded by aggression.

Measuring Seclusion in Psychiatric Intensive Care: Development and Measurement Properties of the Clinical Seclusion Checklist

Background: Acute psychiatric units in general hospitals must ensure that acutely disturbed patients do not harm themselves or others, and simultaneously provide care and treatment and help patients regain control of their behavior. This led to the development of strategies for the seclusion of a patient in this state within a particular area separated from other patients in the ward. While versions of this practice have been used in different countries and settings, a systematic framework for describing the various parameters and types of seclusion interventions has not been available. The aims of the project were to develop and test a valid and reliable checklist for characterizing seclusion in inpatient psychiatric care. Methods: Development and testing of the checklist were accomplished in five stages. Staff in psychiatric units completed detailed descriptions of seclusion episodes. Elements of seclusion were identified by thematic analysis of this material, and consensus regarding these elements was achieved through a Delphi process comprising two rounds. Good content validity was ensured through the sample of seclusion episodes and the representative participants in the Delphi process. The first draft of the checklist was revised based on testing by clinicians assessing seclusion episodes. The revised checklist with six reasons for and 10 elements of seclusion was tested with different response scales, and acceptable interrater reliability was achieved. Results: The Clinical Seclusion Checklist is a brief and feasible tool measuring six reasons for seclusion, 10 elements of seclusion, and four contextual factors. It was developed through a transparent process and exhibited good content validity and acceptable interrater reliability. Conclusion: The checklist is a step toward achieving valid and clinically relevant measurements of seclusion. Its use in psychiatric units may contribute to quality assurance, more reliable statistics and comparisons across sites and periods, improved research on patients' experiences of seclusion and its effects, reduction of negative consequences of seclusion, and improvement of psychiatric intensive care.

Factors associated with the use of mechanical restraint in a mental health hospitalization unit: 8-year retrospective analysis

WHAT IS ALREADY KNOWN ABOUT THE TOPIC?: Our present understanding of mechanical restraint is heterogenous, largely due to the important differences between countries/regions. In Spain, the use of this restrictive practice is not regulated, nor is its use protocolized. Previous studies that have investigated the impact of organizational factors and changes in these protocols are often short and not conducted within a framework designed to establish a long-term plan for reducing the use of mechanical restraint. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: We demonstrate that the implementation of administrative and protocol changes in our psychiatric unit significantly reduced the use of mechanical restraint, thus laying the foundations for a regulatory framework. Our analysis shows that the profile of patients who require mechanical restraint is highly variable, but that certain clinical and institutional aspects within the framework of a long-term plan for the reduction in mechanical restraint can be targeted with long-lasting positive effects. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Organizational changes focussed on training staff, promoting family support and requiring the registration and close monitoring of episodes empower the role of the nursing staff in the prevention, monitoring and regulation of mechanical restraint. ABSTRACT: Introduction Mechanical restraint is a controversial restrictive practice to manage agitation or violent behaviour. Numerous studies have evaluated the factors and organizational changes that influence on mechanical restraint, but only for short time periods. None of those studies have assessed the effects of measures applied within the framework of a long-term plan to reduce the use of mechanical restraint. Given the lack of specific legislation in Spain, more data are required for its proper regulation. Aim/Question To evaluate the risk factors associated and the impact of specific measures designed to minimize the application of mechanical restraint in an acute mental health unit over an 8-year period and previous observation of 5 years. Methods Cross-sectional study based on a retrospective analysis of mechanical restraint records. We compared admissions requiring ≥one episode of restraint versus admissions not requiring this coercive measure. Results Between 2007 and 2014, 412 admissions (12%) required mechanical restraint. The data show that the measures applied in the previous five years had significantly reduced the total hours of restraint per semester. The factors associated with admissions requiring mechanical restraint were involuntary, unscheduled and longer admissions. The best predictor of restraint was involuntary admission (OR = 6.37), followed by the diagnosis of personality disorder (OR = 5.01). Discussion Identification of the factors associated with mechanical restraint would allow for early detection strategies. Our results provide additional evidence on the usefulness of organizational changes to reduce coercive measures, even in a country without specific legislation. Implications for Practice Organizational changes, such as staff training and increased family support during admission of episodes of mechanical restraint, can reduce the use of this measure. These measures also give the nursing staff greater responsibility in terms of their role in registering and monitoring the restrictive practice, thus helping to prevent or minimize the use of mechanical restraint.

Effect of the introduction of immediate judge's decisions in 2018 on the use of coercive measures in psychiatric hospitals in Germany: a population-based study

Background

On 23 July 2018, the German Constitutional Court decided that mechanical restraint in psychiatric patients lasting longer than 30 minutes requires a judge's immediate decision. On the same day, the German Association for Psychiatry and Psychotherapy published its guideline on the prevention of coercion and violence. The registry for coercive measures in the federal state of Baden-Wuerttemberg, available since 2015 and comprising all 32 hospitals licensed to admit involuntary patients, has made it possible to evaluate the effect of the legal change, considered the strongest intervention ever in Germany to reduce coercion.

Methods

We analysed the mean percentage of patients subjected to coercive measures and the mean cumulative duration of these interventions in ICD-10 diagnostic groups in psychiatric hospitals from 2017 compared to 2019 among a total of 233,0273 admissions.

Findings

The percentage of patients subjected to any kind of freedom-restricting coercion decreased from 6·6% in 2017 to 5·8% in 2019 (p = 0·000). Accordingly, the percentage of patients subjected to mechanical restraint decreased from 4·8% to 3·6% in 2019 (p = 0·000). At the same time, the percentage of patients subjected to seclusion increased from 2·9% to 3·3% (p = 0·000). The median cumulated duration of restraint and seclusion per affected case decreased from 12·5 to 11·9 hrs (p = 0·001).

Interpretation

There is clear evidence that a strong legal intervention was effective in reducing the use of coercive measures under routine conditions.

Funding

The registry is funded by the Ministry of Social Welfare and Integration.

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.

Predicting the time trend of first episodes of aggressive behaviors in pediatric psychiatric inpatient units

The goal of the current study is to assess whether the scores of Brief Rating of Aggression by Children and Adolescents (BRACHA) at the emergency room (ER) can predict the aggressive incidents at pediatric psychiatric inpatient units. The study aims to identify predictors for two outcome measurements: 1) hazard rates for the first aggressive incident and 2) numbers of days between admission and the first aggressive incident, using the Cox regression model and Poisson regression model, respectively. The clinical records of a total of 5,610 adolescents admitted into the pediatric psychiatric inpatient units of Cincinnati Children's Hospital Medical Center were extracted for the analysis. The aggressive incident was defined as a score >0 from any category of the Overt Aggression Scale (OAS) and the high-aggressive incident was defined as a score ≥ 2 from any category of the OAS. The results indicate that the BRACHA score was not associated with high-aggressive incidents (hazard ratio: 0.98, p = 0.7543). Similarly, the BRACHA scores was only associated with the number of days from admission to the first aggressive incident (Poisson regression coefficient: 0.24, p < 0.0001) but not the number of days from admission to the first high-aggressive incident (Poisson regression coefficient: 0.03, p = 0.3994). Furthermore, the second peak of first aggressive incidents during the hospitalization highlights the importance of interventions at the end of the inpatient treatment course. To summarize, BRACHA scores based on initial assessments at the ER could correlate with first aggressive incidents, but not the first high-aggressive incidents.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

Number of Seclusions in the Netherlands Higher in the 7 Years Since the End of a Nationwide Seclusion-Reduction Program

Introduction: Between 2006 and 2012 the Dutch government funded a nationwide program for reducing the use of seclusion. Although an initial first trend study showed that the reported number of seclusions declined during the program, the objective of a 10% annual decrease was not met. We wished to establish whether the decline had continued after funding ended in 2012. Method: Using quasi Poisson time series modeling, we retrospectively analyzed the nationally reported numbers of seclusion and involuntary medication between 1998 and 2019, i.e., before, during and after the end of the nationwide program, with and without correction for the number of involuntary admissions. Results: With and without correction for the number of involuntary admissions, there were more seclusions in the seven years after the nationwide program than during the nationwide program. Although the reported number of involuntary medications also increased, the rate of increase was slower after the end of the nationwide program than before. Conclusions: Rather than continuing to decrease after the end of the nationwide program, the number of seclusions rose. This may mean that interventions intended to reduce the use of seclusion within this program are not properly sustained in daily clinical care without an ongoing national program.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Seclusion, restraint, and involuntary medication in Finnish psychiatric care: a register study with root-level data

Purpose: Despite potentially harmful effects, seclusion, restraint, and involuntary medication continue to be frequently applied in psychiatric care. These restrictive measures are often examined by means of registers, but homogeneous practices in the measurement and description seem to be missing. This nationwide register study aimed to examine the use of seclusion, mechanical and physical restraint, and involuntary medication in Finland.Material and methods: Root-level register data concerning the year 2017 were collected directly from 140 inpatient psychiatric wards within 21 organizations. The data were analyzed statistically.Results: In 2017, the most used restrictive measure in Finnish psychiatric wards was seclusion (4006 episodes), followed by involuntary medication (2187 episodes), mechanical restraint (2113 episodes) and physical restraint (1064 events). Similarly, the duration of seclusion episodes was longer than the duration of restraint episodes. Remarkable variation between wards in the use of seclusion, restraint and involuntary medication was observable. A negative binomial regression model (NB2) was used to analyze the associations between the use of restrictive measures and regional variables concerning demography, health, substance abuse, and socio-economic status, but reliable interpretations were impossible to generate.Conclusion: This study provides detailed and unique data on the use of seclusion, restraint and involuntary medication in Finland. Compared to previous national-level data, this study highlights the importance of collecting root-level data. Future research should use registries and describe the associations between the use of restrictive measures and ward-level factors, patient-level characteristics, and societal factors.

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

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

Aims to Reduce Coercive Measures in Forensic Inpatient Treatment: A 9-Year Observational Study

Protecting the human rights is particularly important within the forensic context because patients in forensic psychiatry are not admitted voluntarily and so the treatment itself is of a coercive nature. Coercive measures (i.e., actions against the will of the patient such as forced medication, seclusion or restraint) form an additional incision of personal rights. Although the use of coercion within forensic psychiatric institutions remains controversial, little empirical research has been conducted on the use of coercive measures within forensic settings. The study presented here can contribute to close this research gap by informing about rates of coercive measures within the present institution. National and international organizations on the prevention of torture or inhuman or degrading treatment have emphasized the need to keep the incidents of coercive measures to a minimum. Criticisms by such organizations on high rates of seclusion, restraint, and compulsory medication have led to organizational changes within the present institution which is Switzerland's largest forensic clinic with an average of 124 patients per year. After a first visit of such a committee, e.g., the detailed documentation of coercive measures became obligatory and part of special reports. Changes in the use of coercive measures are presented here. Data on coercive measures was analyzed for years 2010 to 2018. With respect to the most invasive coercive measurement, restraint, a minimum of four patients in 2017 and a maximum of 14 patients in 2010 have been subject to this form of coercive measurement. A minimum of sixteen patients in 2012 and a maximum of 40 patients in 2010 were secluded. Though total number and duration show a trend towards a reduction in severity of coercive measures on average, a few patients are not responsive to deescalating interventions. Preventive mechanisms, documentation standards, and efforts to ensure humane and adequate treatment are discussed under ethical considerations of coercive measures within court mandated treatment.

European Psychiatric Association (EPA) guidance on quality assurance in mental healthcare

Purpose:

To advance the quality of mental healthcare in Europe by developing guidance on implementing quality assurance.

Methods:

We performed a systematic literature search on quality assurance in mental healthcare and the 522 retrieved documents were evaluated by two independent reviewers (B.J. and J.Z.). Based on these evaluations, evidence tables were generated. As it was found that these did not cover all areas of mental healthcare, supplementary hand searches were performed for selected additional areas. Based on these findings, fifteen graded recommendations were developed and consented by the authors. Review by the EPA Guidance Committee and EPA Board led to two additional recommendations (on immigrant mental healthcare and parity of mental and physical healthcare funding).

Results:

Although quality assurance (measures to keep a certain degree of quality), quality control and monitoring (applying quality indicators to the current degree of quality), and quality management (coordinated measures and activities with regard to quality) are conceptually distinct, in practice they are frequently used as if identical and hardly separable. There is a dearth of controlled trials addressing ways to optimize quality assurance in mental healthcare. Altogether, seventeen recommendations were developed addressing a range of aspects of quality assurance in mental healthcare, which appear usable across Europe. These were divided into recommendations about structures, processes and outcomes. Each recommendation was assigned to a hierarchical level of analysis (macro-, meso- and micro-level).

Discussion:

There was a lack of evidence retrievable by a systematic literature search about quality assurance of mental healthcare. Therefore, only after further topics and search had been added it was possible to develop recommendations with mostly medium evidence levels.

Conclusion:

Evidence-based graded recommendations for quality assurance in mental healthcare were developed which should next be implemented and evaluated for feasibility and validity in some European countries. Due to the small evidence base identified corresponding to the practical obscurity of the concept and methods, a European research initiative is called for by the stakeholders represented in this Guidance to improve the educational, methodological and empirical basis for a future broad implementation of measures for quality assurance in European mental healthcare.

Ethical consideration on use of seclusion in mental health services

Seclusion was widely used in mental health service, which had caused various negative effects on patients and nurses. In China, the clinical use of seclusion was gradually increasing, which had led to ethical dilemma and had gained public concern. This article aimed to synthesize the ethical issue according to the principle of autonomy, justice, beneficence, and non-maleficence. Given that nursing workforce was limited and work burden among psychiatric nurses was heavy, seclusion was one of coercive interventions managing aggressive behavior. In relation to cope with ethical dilemma, it was proposed to improve therapeutic environment, and to apply de-escalation technique. Additionally, reducing clinical use and adverse effects of seclusion was also important, this goal would be achieved by building appropriate patient-nurse relationship, increasing staff engagement, and promoting guideline of seclusion.

Reflecting on the Reasons Pros and Cons Coercive Measures for Patients in Psychiatric and Somatic Care: The Role of Clinical Ethics Consultation. A Pilot Study

Background and aim: Coercive measures in patient care have come under criticism leading to implement guidelines dedicated to the reduction of coercion. This development of bringing to light clinical ethics support is hoped to serve as a means of building up awareness and potentially reducing the use of coercion. This study explores the specific features of ethics consultation (EC) while dealing with coercion. Material and method: Basel EC documentation presents insight to all persons involved with a case. The EC database of two Basel university hospitals was developed on the grounds of systematic screening and categorization by two reviewers. One hundred fully documented EC cases databased from 2013 to 2016 were screened for the discussion of coercive measures (somatic hospital and psychiatry: 50% cases). Results: Twenty-four out of 100 EC cases addressed coercion in relation to a clinically relevant question, such as compulsory treatment (70.8%), involuntary committal (50%), or restricting liberty (16.6%). Only 58.3% of EC requests mentioned coercion as an ethical issue prior to the meeting. In no case was patient decisional capacity given, capacity was impaired (43.5%), not given (33.3%), or unclear (21.7%; one not available). Discussion: As clinical staff appears sensitive to perceiving ethical uncertainty or conflict, but less prepared to articulate ethical concern, EC meetings serve to "diagnose" and "solve" the ethical focus of the problem(s) presented in EC. Patient decisional incapacity proved to be an important part of reasoning, when discussing the principle of harm prevention. While professional judgment of capacity remains unsystematic, rationality or even ethicality of decision making will be hampered. The documented EC cases show a variety of decisions about whether or not coercion was actually applied. Ethical reasoning on the competing options seemed to be instrumental for an unprejudiced decision complying with the normative framework and for building a robust consensus. Conclusions: The recommendation is whether EC should be used as a standard practice whenever coercion is an issue-ideally before coercion is applied, or otherwise. Moreover, more efforts should be made toward early and professional assessment of patient capacity and advance care counseling including the offer of advance directives.

Factors influencing decisions of mental health professionals to release service users from seclusion: A qualitative study

AIM

This study aims to explore and understand factors influencing the decisions of mental health professionals releasing service users from seclusion.

BACKGROUND

Seclusion should only be used as a last resort and for the minimum possible duration. Current evidence outlines which service users are more likely to be secluded, why and what influences professionals' decision to seclude. Little is known about factors professionals consider when releasing service users.

DESIGN

A qualitative study was undertaken to explore factors which influence decision-making of mental health professionals when terminating episodes of seclusion.

METHODS

Semi-structured face-to-face interviews with 21 professionals were undertaken between May 2017-January 2018. Framework analysis was used to systematically manage, analyse, and identify themes, while maintaining links to primary data and providing a transparent audit trail.

RESULTS

Six themes were identified where professionals looked for service users to demonstrate cooperation and compliance before they would be released. Decisions were subjective, being influenced by the experience and composition of the review team, the availability of resources plus the emotional tone and physical environment of the ward. Release could be delayed by policy and protocol.

CONCLUSION

Professionals should have greater awareness of factors that hinder or facilitate decisions to release service from seclusion and an understanding of how service user views and involves in decisions regarding seclusion should be explored.

IMPACT

Senior staff should be available to facilitate release at the earliest opportunity. Staff should ensure that policy and procedures do not prolong the time service users remain secluded.

Compulsory Admission to Psychiatric Wards-Who Is Admitted, and Who Appeals Against Admission?

Background: When persons with a mental illness present a danger to themselves or others, involuntary hospital admission can be used to initiate an immediate inpatient treatment. Often, the patients have the right to appeal against compulsory admission. These processes are implemented in most mental health-care systems, but regulations and legal framework differ widely. In the Swiss canton of Basel-Stadt, a new regulation was implemented in January 2013. While the current literature holds some evidence for factors associated with involuntary admission, knowledge on who uses the right to appeal against admission is sparse. Aims: The study aims to examine if specific sociodemographic and clinical characteristics are associated with involuntary admission and with an appeal against the compulsory admission order. Method: Routine clinical data of all inpatient cases admitted during the period from January 2013 to December 2015 at the Psychiatric University Hospital Basel were extracted. Generalized estimating equation (GEE) analyses were used to examine the association of sociodemographic and clinical characteristics with "involuntary admission" and "appeal against compulsory admission order." Results: Of the 8,917 cases included in the present study, 942 (10.6%) were admitted involuntarily. Of these, 250 (26.5%) lodged an appeal against the compulsory admission order. Compared with cases admitted on a voluntary legal status, cases admitted involuntarily were older and were admitted more often during the nighttime or weekend. Moreover, involuntarily admitted cases had more often a principal diagnosis of a schizophrenia spectrum disorder. Patients from cases where an appeal was lodged were more often female, had more often Swiss nationality, and were more often diagnosed with schizophrenia spectrum disorder. Conclusion: Despite legal changes, the frequency of involuntary admissions in the observed catchment area seems to be relatively stable across the last 20 years. The percentage of appeals has decreased from 2000 to 2015, and only comparably few patients make use of the possibility to appeal. Better knowledge of the regulations, higher social functioning, and lower insight into illness might be associated with a higher probability of lodging an appeal. Future research should examine if specific patient groups are in need of additional assistance to exert their rights to appeal.

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

International comparative studies show that Dutch seclusion rates are relatively high. Therefore, several programs to change this practice were developed and implemented. The purpose of this study was to examine the impact of a seclusion reduction program over a long time frame, from 2004 until 2013. Three phases could be identified; the phase of development and implementation of the program (2004-2007), the project phase (2008-2010) and the consolidation phase (2011-2013). Five inpatient wards of a mental health institute were monitored. Each ward had one or more seclusion rooms. Primary outcome were the number and the duration of seclusion incidents. Involuntary medication was monitored as well to rule out substitution of one coercive measure by another. Case mix correction for patient characteristics was done by a multi-level logistic regression analysis with patient characteristics as predictors and hours seclusion per admission hours as outcome. Seclusion use reduced significantly during the project phase, both in number (-73%) and duration (-80%) and was not substituted by the use of enforced medication. Patient compilation as analyzed by the multi- level regression seemed not to confound the findings. Findings show a slight increase in number and seclusion days over the last year of monitoring. Whether this should be interpreted as a continuous or temporary trend remains unclear and is subject for further investigation.

[Predictive factors of seclusion duration in patients hospitalized in psychiatry settings. A prospective multisite study in the DTRF Paris-Sud]

INTRODUCTION

In psychiatric inpatient settings seclusion is a last resort to ensure the safety of the patient, other patients, and staff from disturbed behaviors. Despite its major interest for patients, seclusion could negatively impact treatment adherence and patient/staff relationships. Indeed, some secluded patients report a feeling of guilt during the measure and do not consider seclusion to be a healthcare intervention. To be more beneficial and to reduce the feeling by patients of being forced, seclusions should be as short and rare as possible. In other words, measures to reduce seclusion are available and have been clearly identified. Such measures could be applied, in the first instance, in patients with longer duration. In this way, the aim of this study was to investigate predictive factors of a seclusion of long duration.

METHODS

Our study was based on the dataset of the EPIC study, an observational prospective French multicenter study of seclusion and restraint. The EPIC study occurred in seven French psychiatric hospitals in the southern region of Paris. Inclusions were realized for 73days and allowed a data collection of 302 seclusion measures. Of these measures 236 were effectively a seclusion in a standardized room. Because the median duration was 7days, we defined two groups of patients: duration<7days and duration ≥ 7 days. Our variable to be explicated was duration ≥ 7 days. Explicative variables available in EPIC study were age, sex, forced hospitalization, autoagressivity, heteroagressivity, use of sedative treatment (oral or intramuscular), history of seclusion and patient diagnoses. We used bivariate and multivariate analyses to explore the association between a seclusion duration ≥ 7 days and explicative variables. Diagnoses were classified as psychotic disorders, mood disorders and others diagnoses. To be included in multivariate logistic regressions, diagnoses were treated as dummy variables (mood disorder vs psychotic disorders; psychotic disorders vs others; mood disorders vs others). Statistical analyses were performed using SPSS software 20.0 and R 3.4.0.

RESULTS

Of the 236 measures of seclusion the mean age was 38.2 (±12.8), 196 (83%) patients were forcibly hospitalized prior to their seclusion, 147 (62%) had a diagnosis of psychotic disorder, 43 (18%) a diagnosis of mood disorder and 33 (14%) an "other diagnosis". Mean duration was 10.2 (1.5) days and median was 7.1 days. One hundred and thirty-five (47%) patients were in the group of duration ≥ 7 days. In bivariate analyses, variables associated with a duration ≥ 7 days were: being in forced hospitalization prior to the seclusion (P=0.04), administration of a sedative treatment (P=0.01) and against the group of others diagnoses the diagnosis of mood disorders (P<0.0005) and psychotic disorders (P=0.001). Multivariate analyses showed that, against the group of other diagnoses, the group of psychotic disorders [OR=3.3, CI 95% (1.3-8.4), P=0.01], the group of mood disorder [OR=2.7, CI 95% (1.4-4.9), P=0.002] and administration of sedative treatment [OR=8.1, CI 95% (2.0-32.5), P=0.003] were significantly associated with a duration ≥ 7 days. These results were independent from other confusion variables. Considering the hospitalization status, psychotic disorders was the only diagnosis which showed an association between duration ≥ 7 days and forced hospitalization [OR=2.9 CI 95% (1.1-7.8), P=0.03].

CONCLUSION

Our study highlighted two profiles of higher risk to remain ≥ 7days in seclusion. The first one is patients with a diagnosis of mood disorder who needed sedative treatment. The second one is patients with a diagnosis of psychotic disorder who needed sedative treatment and forced hospitalized before seclusion. Thus, these two profiles could be a good target to practice, in the first instance, measures to reduce seclusion duration in psychiatry settings.

Involuntary admission in Norwegian adult psychiatric hospitals: a systematic review

Background

It is an important objective of the psychiatric services to keep the use of involuntary procedures to a minimum, as the use of coercion involves clinical, ethical, and legal issues. It has been claimed that Norway has a relatively high rate of involuntary admissions. We reviewed the peer-reviewed literature on the use of involuntary admission in Norway, with the purpose of identifying the current state of knowledge and areas in need of further research.

Methods

A systematic review following the PRISMA statement was conducted. We searched the electronic databases PsycInfo, PubMed, Web of Science, CINAHL, and Embase for studies relating to involuntary admission to Norwegian adult psychiatric hospitals published in the period 1 January 2001 to 8 August 2016. The database searches were supplemented with manual searches of relevant journals, reference lists, and websites.

Results

Seventy-four articles were included and grouped into six categories based on their main topics: Patients’ experiences, satisfaction and perceived coercion (21 articles), the Referral and admission process (11 articles), Rates of admission (8 articles), Characteristics of the patients (17 articles), Staff attitudes (9 articles), and Outcomes (8 articles). Four of the included articles described intervention studies. Fifty-seven of the articles had a quantitative design, 16 had a qualitative design, and one a mixed-method design. There was a broad range of topics that were studied and considerable variation in study designs. The findings were largely in line with the international literature, but the particularities of Norwegian legislation and the Norwegian health services were reflected in the literature. The four intervention studies explored interventions for reducing rates of involuntary admission, such as modifying referring routines, improving patient information procedures, and increasing patients’ say in the admission process, and represent an important avenue for future research on involuntary admission in Norway.

Conclusions

The review suggests that Norway has a relatively high rate of involuntary admissions. The identified studies represent a broad mix of topics and designs. Four intervention studies were identified. More studies with strong designs are needed to bring research on involuntary admission in Norway to a next level.

Electronic supplementary material

The online version of this article (10.1186/s13033-018-0189-z) contains supplementary material, which is available to authorized users.

Use of mechanical and pharmacological restraint over an eight-year period and its relation to clinical factors

BACKGROUND

Use of restraint and finding the balance between security and ethics is a continuous dilemma in clinical psychiatry. In daily clinic and in planning health-care service, knowledge on the characteristics of restraint situations is necessary to optimize its use and avoid abuse.

METHODS

We describe characteristics in the use of pharmacological and mechanical restraint in psychiatric acute wards in a hospital in Middle Norway over an eight-year period. Data on all cases of mechanical and pharmacological restraint from 2004 to 2011 were retrospectively collected from hand-written protocols. Complementary information on the patients was obtained from the hospital patient administrative system.

RESULTS

Restraint in acute wards was used on 13 persons per 100,000 inhabitants annually. The percentage of admitted patients exposed to restraint was 1.7%, with a mean of 4.5 cases per exposed patient. Frequency per 100 admitted patients varied from 3.7 (in 2007) to 10 (in 2009). The majority of restraint cases concerned male patients under 50 years and with substance-abuse, psychotic, or affective disorders. Significantly more coercive means were used during daytime compared to night and morning. There was a significant increase in pharmacological coercion during spring and mechanical coercion during summer.

CONCLUSIONS

Restraint was used on 1.7% of admitted patients, representing 13 per 100,000 inhabitants per year. Use of restraint was higher during certain periods of the day and was associated with the patient's diagnosis, age, gender, and legal status of hospitalization. There was a marked variation over the years.

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.

Prolonged use of seclusion and mechanical restraint in mental health services: A statewide retrospective cohort study

Seclusion and mechanical restraint are restrictive interventions that should be used only as a last resort and for the shortest possible time, yet little is known about duration of use in the broader context. Adult area mental health services throughout Victoria, Australia, were asked to complete a report form for prolonged episodes of seclusion (>8 hours) and mechanical restraint (>1 hour). The present, retrospective cohort study aimed to understand the individual (age, sex, type of service, duration of intervention) and contextual factors associated with prolonged use of restrictive interventions. Contextual factors describing the reasons for prolonged use of the restrictive interventions were captured qualitatively, and then coded using content analysis. Median duration was compared across individual factors using Mann-Whitney U-tests. During 2014, 690 episodes of prolonged restrictive intervention involving 311 consumers were reported. Close to half (n = 320, 46%) involved mechanical restraint. Seclusion episodes (n = 370) were longer in forensic mental health services compared to adult area mental health services (median: 24 hours and 18 min vs 16 hours and 42 min, P < 0.001). Mechanical restraint episodes (n = 320) were shorter in forensic mental health services compared to adult area mental health services (median: 3 hours and 25 min vs 4 hours and 15 min, P = 0.008). Some consumers were subject to multiple episodes of prolonged seclusion (55/206, 27%) and/or prolonged mechanical restraint (31/131, 24%). The most commonly occurring contextual factor for prolonged restrictive interventions was 'risk of harm to others'. Means for reducing the use of prolonged restrictive interventions are discussed in light of the findings.

A Blind Spot? Screening for Mild Intellectual Disability and Borderline Intellectual Functioning in Admitted Psychiatric Patients: Prevalence and Associations with Coercive Measures

Background

Failure to detect psychiatric patients’ intellectual disabilities may lead to inappropriate treatment and greater use of coercive measures.

Aims

In this prospective dynamic cohort study we screened for intellectual disabilities in patients admitted to psychiatric wards, and investigated the use of coercive measures with these patients.

Methods

We used the Screener for Intelligence and Learning disabilities (SCIL) to screen patients admitted to two acute psychiatric wards, and assessed patient characteristics and coercive measures during their stay and over the last 5 years.

Results

Results on the SCIL suggested that 43.8% of the sample had Mild Intellectual Disability or Borderline Intellectual Functioning (MID/BIF). During their current stay and earlier stays in the previous 5 years, these patients had an increased risk of involuntary admission (OR 2.71; SD 1.28–5.70) and coercive measures (OR 3.95, SD 1.47–10.54).

Conclusions

This study suggests that functioning on the level of MID/BIF is very prevalent in admitted psychiatric patients and requires specific attention from mental health care staff.

Seclusion and enforced medication in dealing with aggression: A prospective dynamic cohort study

BACKGROUND

In the Netherlands, seclusion is historically the measure of first choice in dealing with aggressive incidents. In 2010, the Mediant Mental Health Trust in Eastern Netherlands introduced a policy prioritising the use of enforced medication to manage aggressive incidents over seclusion. The main goal of the study was to investigate whether prioritising enforced medication over seclusion leads to a change of aggressive incidents and coercive measures.

METHODS

The study was carried out with data from 2764 patients admitted between 2007 and 2013 to the hospital locations of the Mediant Mental Health Trust in Eastern Netherlands, with a catchment area of 500,000 inhabitants. Seclusion, restraint and enforced medications as well as other coercive measures were gathered systematically. Aggressive incidents were assessed with the SOAS-R. An event sequence analysis was preformed, to assess the whether seclusion, restraint or enforced medication were used or not before or after aggressive incidents.

RESULTS

Enforced medication use went up by 363% from a very low baseline. There was a marked reduction of overall coercive measures by 44%. Seclusion hours went down by 62%. Aggression against staff or patients was reduced by 40%.

CONCLUSIONS

When dealing with aggression, prioritising medication significantly reduces other coercive measures and aggression against staff, while within principles of subsidiarity, proportionality and expediency.

Comparison of restraint data from four countries

BACKGROUND

Previous studies comparing restraint data from different countries had to rely on randomly published data and showed wide variance in the prevalence of restraint between countries.

AIM

To systematically compare datasets from four similar European countries with regard to restraint prevalence.

METHODS

We analysed whole country or area datasets on restraint from Wales, Ireland, Germany and the Netherlands systematically, thus excluding selection, patient and setting bias. Learning disability (LD) and forensic settings were analysed separately. Differences in proportions between countries were tested by means of Chi square, with number of admissions, admission days and catchment area as denominator and counts of restraint as numerators.

RESULTS

Full datasets were obtained allowing calculations of total admissions, total restraint numbers, numbers of patients involved and total occupied bed days. Data for Ireland is from 2012 and from 2013 for the other three countries. The percentage of patients exposed to restraint varies between 4.5 and 9.4 %. The average number of restraints per patient is stable at around 3 in all countries. Patient numbers affected by restraint per 100 occupied bed days per month vary between 0.095 and 0.200. The Netherlands have the highest use of seclusion (79 %), the longest restraint times and low use of enforced medication. Wales the lowest use of seclusion (2 %), followed by Ireland (29 %) and Germany (49 %). Events per 100 admissions per month vary between 17 and 21. Patients affected by restraint per 100 admissions per month vary between 5.4 and 7.5. LD services account for a disproportionately high number of restraint events.

CONCLUSION

Patient related restraint data are remarkably similar between countries. Type and length of restraint still vary significantly.

'Big data' in mental health research: current status and emerging possibilities

PURPOSE

'Big data' are accumulating in a multitude of domains and offer novel opportunities for research. The role of these resources in mental health investigations remains relatively unexplored, although a number of datasets are in use and supporting a range of projects. We sought to review big data resources and their use in mental health research to characterise applications to date and consider directions for innovation in future.

METHODS

A narrative review.

RESULTS

Clear disparities were evident in geographic regions covered and in the disorders and interventions receiving most attention.

DISCUSSION

We discuss the strengths and weaknesses of the use of different types of data and the challenges of big data in general. Current research output from big data is still predominantly determined by the information and resources available and there is a need to reverse the situation so that big data platforms are more driven by the needs of clinical services and service users.

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.

The Use of Physical Restraint in Norwegian Adult Psychiatric Hospitals

Background. The use of coercion within the psychiatric services is problematic and raises a range of ethical, legal, and clinical questions. “Physical restraint” is an emergency procedure used in psychiatric hospitals to control patients that pose an imminent physical danger. We wished to review the literature published in scientific peer-reviewed journals describing studies on the use of physical restraint in Norway, in order to identify the current state of knowledge and directions for future research. Design. The databases PubMed, PsycINFO, CINAHL, Web of Science, and Embase were searched for studies relating to physical restraint (including holding) in Norwegian psychiatric hospitals, supplemented with hand searches. Results. 28 studies were included. Most of the studies were on rates of restraint, but there were also some studies on perceptions of patients and staff, case studies, and ethnographic studies. There was only one intervention study. There are differences in use between wards and institutions, which in part may be explained by differences in patient populations. Staff appear to be less negative to the use of restraint than patients. Conclusions. The studies that were identified were primarily concerned with rates of use and with patients' and staff's perspectives. More interventional studies are needed to move the field forward.

Comparing the effect of non-medical mechanical restraint preventive factors between psychiatric units in Denmark and Norway

BACKGROUND

The use of mechanical restraint (MR) is controversial, and large differences regarding the use of MR are often found among countries. In an earlier study, we observed that MR was used twice as frequently in Denmark than Norway.

AIMS

To examine how presumed MR preventive factors of non-medical origin may explain the differing number of MR episodes between Denmark and Norway.

METHODS

This study is a cross-sectional survey of psychiatric units. Linear regression was used to assess the confounding effects of the MR preventive factors, i.e. whether a difference in the impact of these factors is evident between Denmark and Norway.

RESULTS

Six MR preventive factors confounded [∆exp(B)> 10%] the difference in MR use between Denmark and Norway, including staff education (- 51%), substitute staff (- 17%), acceptable work environment (- 15%), separation of acutely disturbed patients (13%), patient-staff ratio (- 11%), and the identification of the patient's crisis triggers (- 10%).

CONCLUSIONS

These six MR preventive factors might partially explain the difference in the frequency of MR episodes observed in the two countries, i.e. higher numbers in Denmark than Norway. One MR preventive factor was not supported by earlier research, the identification of the patient's crisis triggers; therefore, more research on the mechanisms involved is needed.

CLINICAL IMPLICATIONS

None of the six MR preventive factors presents any adverse effects; therefore, units in Denmark and Norway may consider investigating the effect of implementing, the identification of the patient's crisis triggers, an increased number of staff per patient, increased staff education, a better work environment and reduced use of substitute staff in practice.

Seclusion and the importance of contextual factors: An innovation project revisited

Variation in seclusion rates between psychiatric facilities cannot be adequately explained by patient characteristics alone and there is a growing awareness of the influence of 'cultural' and staff factors on the use of seclusion. In this study, staff variables as well as seclusion parameters were investigated during the implementation of an innovation project, against the background of an institutional program to reduce the use of coercive measures. The results demonstrate the impact of confidence within the team, staffing level and communication with the patient on nurses' decisions on seclusion. The importance of the organizational context is further illustrated by the negative effects of organizational instability on nurses' attitudes and decision making with respect to seclusion, and on seclusion rates. A reduction in the use of seclusion was achieved after the implementation of the innovation project; however, during a period of organizational turmoil, the work engagement scores of staff decreased and the use of seclusion increased. The results of this study show the vulnerability of innovations within the continuously changing organizational context of mental health care.

Impact of the creation and implementation of a clinical management guideline for personality disorders in reducing use of mechanical restraints in a psychiatric inpatient unit

OBJECTIVE

To evaluate the impact of the implementation of a guideline for the management of personality disorders on reducing the frequency of use of mechanical restraints in a psychiatric inpatient unit.

METHOD

This retrospective study was conducted in a psychiatric inpatient unit with 42 beds, which serves an urban area of 330,000 inhabitants. The sample consisted of all patients with a clinical diagnosis of personality disorder (DSM-IV-TR criteria) who were admitted to the unit from January 2010 to December 2010 and from January 2011 to December 2011 (ie, before and after, respectively, the implementation of the guideline). The guideline focused on cluster B disorders and follows a psychodynamic perspective.

RESULTS

Restraint use was reduced from 38 of 87 patients with personality disorders (43.7%) to 3 of 112 (2.7%), for a relative risk of 0.06 (95% CI, 0.02-0.19) and an absolute risk reduction of 41% (95% CI, 29.9%-51.6%). The risk of being discharged against medical advice increased after the intervention, with a relative risk of 1.84 (95% CI, 0.96-3.51). Restraint use in patients with other diagnoses was also reduced to a similar extent.

CONCLUSIONS

The use of mechanical restraints was dramatically reduced after the implementation of a clinical practice guideline on personality disorders, suggesting that these coercive measures might be decreased in psychiatric inpatient units.

[Coercive measures in psychiatric clinics in Germany: current practice (2012)]

BACKGROUND

Due to the decisions of the German Constitutional Court on involuntary medication and the law on the prohibition of video surveillance in psychiatry in Nordrhine-Westfalia there has been an increasing discussion on coercive measures and how to conduct, supervise and prevent them. We conducted an online survey on the current practice of coercive measures in German psychiatric hospitals (2012).

METHOD

An online questionnaire was developed together with the working group for the prevention of violence and coercion in psychiatry and the regional association of psychiatry-experienced people in Baden-Wuerttemberg. The survey was conducted anonymously using the e-mail distribution lists of the psychiatric associations in Germany.

RESULTS

A total of 88 questionnaires from hospitals with obligatory responsibility for a catchment area (19.7% of those addressed) could be analyzed. Of these 99% used internal or external guidelines, 97.5% conducted de-escalation training, 23% participated in external benchmarking on the use of coercive measures. All hospitals used mechanical restraint, approximately 50% seclusion and physical restraint was practiced in 7%. Most, but not all hospital directors reported that mechanical restraint and seclusion were continuously (24/7) monitored. Changes in practice in the years to come were expected by the majority.

CONCLUSIONS

The survey revealed a high critical awareness concerning the use of coercive measures and the willingness to further change the practice.

Clinical and organizational factors related to the reduction of mechanical restraint application in an acute ward: an 8-year retrospective analysis

Background:

The purpose of this study was to describe the frequency of mechanical restraint use in an acute psychiatric ward and to analyze which variables may have significantly influenced the use of this procedure. Methods: This retrospective study was conducted in the Servizio Psichiatrico di Diagnosi e Cura (SPDC) of Modena Centro. The following variables of our sample, represented by all restrained patients admitted from 1-1-2005 to 31-12-2012, were analyzed: age, gender, nationality, psychiatric diagnoses, organic comorbidity, state and duration of admission, motivation and duration of restraints, nursing shift and hospitalization day of restraint, number of patients admitted at the time of restraint and institutional changes during the observation period. The above variables were statistically compared with those of all other non-restrained patients admitted to our ward in the same period. Results: Mechanical restraints were primarily used as a safety procedure to manage aggressive behavior of male patients, during the first days of hospitalization and night shifts. Neurocognitive disorders, organic comorbidity, compulsory state and long duration of admission were statistically significantly related to the increase of restraint use (p<.001, multivariate logistic regression). Institutional changes, especially more restricted guidelines concerning restraint application, were statistically significantly related to restraint use reduction (p<.001, chi2 test, multivariate logistic regression). Conclusion: The data obtained highlight that mechanical restraint use was influenced not only by clinical factors, but mainly by staff and policy factors, which have permitted a gradual but significant reduction in the use of this procedure through a multidimensional approach.

The use of coercive interventions in mental health care in Germany and the Netherlands. A comparison of the developments in two neighboring countries

In this review, we compare the use of coercion in mental health care in Germany and in the Netherlands. Legal frameworks and published data on involuntary commitment, involuntary medication, seclusion, and restraint are highlighted as well as the role of guidelines, training, and attitudes held by psychiatrists and the public. Legal procedures regulating involuntary admission and commitment are rather similar, and so is the percentage of involuntary admissions and the rate per 100,000 inhabitants. However, opposing trends can be observed in the use of coercive interventions during treatment, which in both countries are considered as a last resort after all other alternative approaches have failed. In the Netherlands, for a long time seclusion has been considered as preferred intervention while the use of medication by force was widely disapproved as being unnecessarily invasive. However, after increasing evidence showed that number and duration of seclusions as well as the number of aggressive incidents per admission were considerably higher than in other European countries, attitudes changed within recent years. A national program with spending of 15 million € was launched to reduce the use of seclusion, while the use of medication was facilitated. A legislation is scheduled, which will allow also outpatient coercive treatment. In Germany, the latter was never legalized. While coercive treatment in Germany was rather common for involuntarily committed patients and mechanical restraint was preferred to seclusion in most hospital as a containment measure, the decisions of the Constitutional Court in 2011 had a high impact on legislation, attitudes, and clinical practice. Though since 2013 coercive medication is approvable again under strict conditions, it is now widely perceived as very invasive and last resort. There is evidence that this change of attitudes lead to a considerable increase of the use of seclusion and restraint for some patients.

Psychiatric staff on the wards does not share attitudes on aggression

Background

The concept of ward culture has been proposed as a reason for the often reported differences in treatment decisions when managing inpatient aggression. We therefore studied whether staff on wards actually shares similar perceptions and attitudes about aggression and whether the specialty of the ward on which the staff members work influences these opinions.

Methods

The Attitudes Towards Aggression Scale was used to assess attitudes towards aggression in 31 closed psychiatric wards. Altogether 487 staff members working on the study wards were asked to fill in the scale. Respondent’s gender, age, educational level, working experience on the current ward, and specialty of this ward (acute, forensic, rehabilitation) served as background variables.

Results

Most of the variance found was due to differences between individuals. Belonging to the personnel of a particular ward did not explain much of the variance.

Conclusions

Psychiatric staff on the wards does not share attitudes on aggression. As each staff member has his/her own opinion about aggression, training for dealing with aggression or violent incidents should be done, at least partly, on an individual level. We also suggest caution in using the concept of ward culture as an explanation for the use of restrictive measures on psychiatric wards.

Reduction in the use of seclusion by the methodical work approach

Patient care in a psychiatric setting can benefit from a more systematic, transparent, and goal-driven way of working. The methodical work approach, with its cyclic five phases, provides such an approach: (i) translation of problems into goals; (ii) search for means to realize the goals; (iii) formulation of an individualized plan; (iv) implementation of the plan; and (v) evaluation and readjustment. We examined the effect of the methodical work approach on the use of seclusion at a ward for the intensive treatment of inpatients with psychoses and substance-use disorders. The team of this ward implemented the methodical work approach. Special attention was paid to the involvement of the patient and his/her family in the treatment process and to the role of the coordinating nurse. Compared to control wards within the same hospital, at the ward where the methodical work approach was implemented, a more pronounced reduction was achieved in the number of incidents and in the total hours of seclusion. Implementation of the methodical work approach can contribute to a reduction in the use of seclusion.

Characteristics of patients frequently subjected to pharmacological and mechanical restraint--a register study in three Norwegian acute psychiatric wards

This retrospective study from three catchment-area-based acute psychiatric wards showed that of all the pharmacologically and mechanically restrained patients (n=373) 34 (9.1%) had been frequently restrained (6 or more times). These patients accounted for 39.2% of all restraint episodes during the two-year study period. Adjusted binary logistic regression analyses showed that the odds for being frequently restrained were 91% lower among patients above 50 years compared to those aged 18-29 years; a threefold increase (OR=3.1) for those admitted 3 times or more compared to patients with only one stay; and, finally, a threefold increase (OR=3.1) if the length of stay was 16 days or more compared to those admitted for 0-4 days. Among frequently restrained patients, males (n=15) had significantly longer stays than women (n=19), and 8 of the females had a diagnosis of personality disorder, compared to none among males. Our study showed that being frequently restrained was associated with long inpatient stay, many admissions and young age. Teasing out patient characteristics associated with the risk of being frequently restraint may contribute to reduce use of restraint by developing alternative interventions for these patients.