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Pedersen ML, Gildberg FA, Baker J, Tingleff EB. A systematic review of interventions to reduce mechanical restraint in adult mental health inpatient settings. Int J Ment Health Nurs 2024; 33:505-522. [PMID: 38017713 DOI: 10.1111/inm.13267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 10/25/2023] [Accepted: 11/13/2023] [Indexed: 11/30/2023]
Abstract
Mechanical restraint is a commonly used restrictive practice worldwide, although reducing its use is an international priority. Interventions to reduce mechanical restraint are needed if reducing mechanical restraint is to succeed. Therefore, this systematic review aimed to examine evaluated evidence-based interventions that seek to reduce the incidence of and/or time in mechanical restraint in adult mental health inpatient settings. The JBI framework was used to guide this systematic review. The search strategy included peer-reviewed primary research literature published between 1999 and 2023. Two authors independently conducted the systematic search, selection process and data extraction process. Forty-one studies were included in this review. Using content analysis, we grouped interventions into four categories: (I) calm-down methods, (II) staff resources, (III) legal and policy changes and (IV) changing staff culture. Interventions to reduce mechanical restraint in adult mental health inpatient settings have shown some promise. Evidence suggests that a range of interventions can reduce the incidence of and/or time in mechanical restraint. However, controlled trials were lacking and consensus was lacking across studies. Furthermore, specific findings varied widely, and reporting was inconsistent, hampering the development of interventions for this issue. Further research is needed to strengthen the evidence base for reducing mechanical restraint in mental health inpatient settings.
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Affiliation(s)
- Martin Locht Pedersen
- Forensic Mental Health Research Unit Middelfart, Department of Regional Health Research, University of Southern Denmark, Middelfart, Denmark
- Psychiatric Department Middelfart, Mental Health Services in the Region of Southern Denmark, Middelfart, Denmark
| | - Frederik Alkier Gildberg
- Forensic Mental Health Research Unit Middelfart, Department of Regional Health Research, University of Southern Denmark, Middelfart, Denmark
- Psychiatric Department Middelfart, Mental Health Services in the Region of Southern Denmark, Middelfart, Denmark
| | - John Baker
- School of Healthcare, University of Leeds, Leeds, UK
| | - Ellen Boldrup Tingleff
- Forensic Mental Health Research Unit Middelfart, Department of Regional Health Research, University of Southern Denmark, Middelfart, Denmark
- Psychiatric Department Middelfart, Mental Health Services in the Region of Southern Denmark, Middelfart, Denmark
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Aragonés-Calleja M, Sánchez-Martínez V. Evidence synthesis on coercion in mental health: An umbrella review. Int J Ment Health Nurs 2024; 33:259-280. [PMID: 37908175 DOI: 10.1111/inm.13248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 10/10/2023] [Accepted: 10/15/2023] [Indexed: 11/02/2023]
Abstract
Coercion in mental healthcare is ubiquitous and affects the physical health, recovery and psychological and emotional well-being of those who experience it. Numerous studies have explored different issues related to coercion, and the present umbrella review aims to gather, evaluate and synthesise the evidence found across systematic reviews. The protocol, registered in the International Prospective Register of Systematic Reviews (PROSPERO registration number: CRD42020196713), included 46 systematic reviews and meta-analyses of primary studies whose main theme was coercion and which were obtained from databases (Medline/PubMed, PsycINFO, EMBASE and CINAHL) and repositories of systematic reviews following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. All the reviews were subjected to independent assessment of quality and risk of bias and were grouped in two categories: (1) evidence on specific coercive measures (including Community Treatment Orders, forced treatment, involuntary admissions, seclusion and restriction and informal coercion), taking into account their prevalence, related factors, effectiveness, harmful effects and alternatives to reduce their use; and (2) experiences, perceptions and attitudes concerning coercion of professionals, mental health service users and their caregivers or relatives. This umbrella review can be useful to professionals and users in addressing the wide variety of aspects encompassed by coercion and the implications for professionals' daily clinical practice in mental health units. This research received funding from two competitive calls.
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Affiliation(s)
- Miriam Aragonés-Calleja
- Mental Health Department, Hospital Padre Jofre, Valencia, Spain
- Department of Nursing, Faculty of Nursing and Chiropody, University of Valencia, Valencia, Spain
| | - Vanessa Sánchez-Martínez
- Department of Nursing, Faculty of Nursing and Chiropody, University of Valencia, Valencia, Spain
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Chong Y, Wang C, Min H, Zhang L, Zhi T, Wu X, Wang Y. Physical Restraint Experience of Patients with Mental Disorders in Mainland China: A Qualitative Study. J Multidiscip Healthc 2024; 17:431-444. [PMID: 38314012 PMCID: PMC10838508 DOI: 10.2147/jmdh.s438269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/16/2024] [Indexed: 02/06/2024] Open
Abstract
Introduction The use of physical restraint (PR) is considered a controversial practice and research in Western countries has demonstrated negative physical and psychological consequences for patients, as well as staff, family members/carers, organisations and society as a whole. However, there are few research reports on restraint experiences of patients with mental disorders in non-Western countries, especially in mainland China. Aim This study aims to explore the subjective experiences and perceptions of patients with psychiatric disorders who have experienced PR in mainland China. Methods Semi-structured interviews were conducted with 8 inpatients with mental disorders in convalescence at a specialized mental health hospital in Shanghai. Interviews were recorded on audiotape and transcribed verbatim. Transcripts were analyzed using thematic analysis. Results Five themes emerged: "perception and understanding of PR", "response to PR", "negative physical and psychological experiences", "unmet care needs during PR" and "changes after PR", which together characterize patients' perceptions, experiences, feelings, and needs in PR. Conclusion The use of PR involves ethical issues and brings negative experiences to patients with mental disorders that cannot be ignored and should be used as a last resort. Different patients have different attitudes and reactions to PR. During PR, patients' physical and psychological needs are not adequately met. Medical staff should give more attention to patients in PR, meet their physical and psychological needs, and actively seek PR alternatives and reduction options based on evidence-based resources on restraint reduction available in the West and the national context and culture of China.
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Affiliation(s)
- Yue Chong
- Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, 200124, People's Republic of China
| | - Can Wang
- Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, 200124, People's Republic of China
| | - Haiying Min
- Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, 200124, People's Republic of China
| | - Lei Zhang
- Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, 200124, People's Republic of China
| | - Tingting Zhi
- Shanghai Baoshan Mental Health Center, Shanghai, 201900, People's Republic of China
| | - Xiaoning Wu
- Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, 200124, People's Republic of China
| | - Yanbo Wang
- Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, 200124, People's Republic of China
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Miodownik C, Friger MD, Teitelbaum A, Demchuk N, Zhuk A, Agababa T, Sokolik S, Lerner PP, Calfon N, Lerner V. Risk factors for coercion length at psychiatric hospitals in Israel: Relationship with staff. Indian J Psychiatry 2024; 66:36-42. [PMID: 38419935 PMCID: PMC10898533 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_814_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 06/27/2023] [Accepted: 11/11/2023] [Indexed: 03/02/2024] Open
Abstract
Background Coercive interventions continue to be applied frequently in psychiatric care when patients are at imminent risk of harming themselves and/or others. Aim The purpose of this study was to demonstrate the relationship between the length of coercion and a variety of factors, including the sociodemographic background of patients, their diagnoses and the characteristics of hospital staff. Methods This is a one-year cross-sectional retrospective study, including records of 298 patients who underwent restraint and/or seclusion interventions in male acute, closed wards in two psychiatric hospitals in Israel. Results A higher proportion of academic nurses to nonacademic nurses on duty leads to a shorter coercion time (P < 0.000). The number of male staff on duty, without any relation to their level of education, also leads to the shortening of the coercion time. Conclusion The presence of registered, academic female nurses, male staff on duty and the administration of medication before coercive measures can reduce the length of restriction.
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Affiliation(s)
- Chanoch Miodownik
- Be’er Sheva Mental Health Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Michael D. Friger
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | | | - Natalya Demchuk
- Be’er Sheva Mental Health Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | | | - Tsipora Agababa
- Be’er Sheva Mental Health Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Shmuel Sokolik
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | | | | | - Vladimir Lerner
- Be’er Sheva Mental Health Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
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O'Callaghan AK, Plunkett R, Kelly BD. Seclusion, Restraint, Therapeutic Alliance, and Legal Admission Status: What Really Matters? J Psychiatr Pract 2022; 28:454-464. [PMID: 36355584 DOI: 10.1097/pra.0000000000000665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To determine the relationships, if any, between use of seclusion and restraint and factors such as demographic parameters, diagnosis, legal admission status (voluntary or involuntary), symptoms, cognitive function, global functioning, therapeutic alliance, attitudes toward medication, and insight, among psychiatry inpatients in Ireland. METHODS We used validated tools to perform detailed assessments of 107 adult psychiatry inpatients admitted to acute psychiatry units at 2 general hospitals in Dublin, Ireland over a 30-month period, between September 2017 and February 2020. RESULTS The most common diagnoses in our sample were affective disorders (46.7%), schizophrenia and related disorders (27.1%), and personality and behavioral disorders (11.2%). Over a quarter (n=29, 27.1%) of the participating patients had involuntary legal status. Of the 107 patients, 11 patients (10.3%) experienced sedation and/or physical restraint, with 9 patients (8.4%) experiencing at least 1 episode of seclusion and 10 patients (9.3%) experiencing at least 1 episode of physical restraint. On the basis of multivariable analyses, seclusion was associated with younger age and involuntary status, while physical restraint was associated with involuntary status. Each multivariable model explained just over one third of the variance in the distribution of these seclusion and restraint practices. CONCLUSIONS Use of seclusion and restraint was most strongly associated with involuntary admission status and, in the case of seclusion, younger age, rather than sex, diagnosis, symptoms, cognitive function, global functioning, therapeutic alliance, attitudes toward medication, or insight. The network of interactions between involuntary status and use of seclusion and restraint merits much closer attention, especially as use of seclusion and physical restraint appears to be associated with involuntary legal status independent of level of symptoms, therapeutic alliance, or insight.
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O'Donovan D, Boland C, Carballedo A. Current trends in restrictive interventions in psychiatry: a European perspective. BJPSYCH ADVANCES 2022. [DOI: 10.1192/bja.2022.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SUMMARY
This article reviews current evidence on the use of coercive measures, including seclusion and restraint, in psychiatric in-patient settings in Europe. There is a particular focus on evidence regarding the use of mechanical restraint. The review seeks to describe when the use of restrictive interventions such as restraint may be necessary, to explore the use of restraint in certain specialist settings and to investigate current laws and European policies on seclusion and restraint. The current rates of restraint in European psychiatric settings are explored, with a discussion of the limitations of the evidence currently available. The article discusses various consequences of seclusion and restraint, potential alternatives to their use and strategies to minimise their use and harm to patients. The use of coercive measures from an international context is considered, to provide context.
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Lynge MC, Dixen ST, Johansen KS, Düring SW, U-Parnas A, Nordgaard J. Patients' experiences with physical holding and mechanical restraint in the psychiatric care: an interview study. Nord J Psychiatry 2022; 77:247-255. [PMID: 35732037 DOI: 10.1080/08039488.2022.2087001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND In the continuous work to reduce the use of coercion in psychiatric care, attention in Denmark has especially been directed towards mechanical restraint. While the use of mechanical restraint is currently decreasing, an increase in other types of coercion is observed (e.g. medication and hour-long episodes of physical holding). Physical holding has, in this cultural context, been considered less intrusive to a patient's autonomy than the use of mechanical restraint. However, no study has yet compared the experiences of the patients on these two types of coercion in the same population. The objective of this study was to explore patients' perspectives on physical holding and mechanical restraint, respectively. METHODS Audio-recorded, semi-structured interviews following an interview guide were conducted with patients sharing their experiences with both types of coercion. The interviews were transcribed verbatim. The analytical approach was based on the principles of thematic content analysis. RESULTS Nine informants were interviewed between September 2020 and April 2021. Four main themes were identified: experiences with physical holding, experiences with mechanical restraint, the effects of coercion on patients and their relation to mental health care, and improved mental health care. CONCLUSION It is inconclusive which type of restraint the patients preferred. This challenges the present hierarchy of coercive measures. To avoid coercion in the first place more communication and time with the patient are needed.
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Affiliation(s)
| | | | - Katrine S Johansen
- Head of Competence Centre for Dual Diagnosis, Mental Health Centre Sct. Hans, Roskilde, Denmark.,University of Southern Denmark National Institute of Public Health, Copenhagen, Denmark
| | - Signe W Düring
- Mental Health Centre Amager, Denmark.,University of Copenhagen, Competence Centre for Dual Diagnosis, Mental Health Centre Sct. Hans, Roskilde, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Annick U-Parnas
- Mental Health Centre Amager, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Julie Nordgaard
- Mental Health Centre Amager, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Ruud T, Haugom EW, Pincus HA, Hynnekleiv T. Measuring Seclusion in Psychiatric Intensive Care: Development and Measurement Properties of the Clinical Seclusion Checklist. Front Psychiatry 2021; 12:768500. [PMID: 35002798 PMCID: PMC8733687 DOI: 10.3389/fpsyt.2021.768500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/23/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Torleif Ruud
- Mental Health Services, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Espen Woldsengen Haugom
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Acute Psychiatry and Psychosis Treatment, Sanderud, Division of Mental Health, Innlandet Hospital Trust, Ottestad, Norway
| | - Harold Alan Pincus
- Department of Psychiatry and Irving Institute for Clinical and Translational Research, Columbia University, New York City, NY, United States
- New York State Psychiatric Institute, New York City, NY, United States
| | - Torfinn Hynnekleiv
- Department of Acute Psychiatry and Psychosis Treatment, Division of Mental Health, Innlandet Hospital Trust, Reinsvoll, Norway
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Mann K, Gröschel S, Singer S, Breitmaier J, Claus S, Fani M, Rambach S, Salize HJ, Lieb K. Evaluation of coercive measures in different psychiatric hospitals: the impact of institutional characteristics. BMC Psychiatry 2021; 21:419. [PMID: 34419009 PMCID: PMC8380405 DOI: 10.1186/s12888-021-03410-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/05/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Epidemiological studies have demonstrated considerable differences in the use of coercive measures among psychiatric hospitals; however, the underlying reasons for these differences are largely unclear. We investigated to what extent these differences could be explained by institutional factors. METHODS Four psychiatric hospitals with identical responsibilities within the mental health care system, but with different inpatient care organizations, participated in this prospective observational study. We included all patients admitted over a period of 24 months who were affected by mechanical restraint, seclusion, or compulsory medication. In addition to the patterns of coercive measures, we investigated the effect of each hospital on the frequency of compulsory medication and the cumulative duration of mechanical restraint and seclusion, using multivariate binary logistic regression. To compare the two outcomes between hospitals, odds ratios (OR) with corresponding 95% confidence intervals (CI) were calculated. RESULTS Altogether, coercive measures were applied in 1542 cases, corresponding to an overall prevalence of 8%. The frequency and patterns of the modalities of coercive measures were different between hospitals, and the differences could be at least partially related to institutional characteristics. For the two hospitals that had no permanently locked wards, certain findings were particularly noticeable. In one of these hospitals, the probability of receiving compulsory medication was significantly higher compared with the other institutions (OR 1.9, CI 1.1-3.0 for patients < 65 years; OR 8.0, CI 3.1-20.7 for patients ≥65 years); in the other hospital, in patients younger than 65 years, the cumulative duration of restraint and seclusion was significantly longer compared with the other institutions (OR 2.6, CI 1.7-3.9). CONCLUSIONS The findings are compatible with the hypothesis that more open settings are associated with a more extensive use of coercion. However, due to numerous influencing factors, these results should be interpreted with caution. In view of the relevance of this issue, further research is needed for a deeper understanding of the reasons underlying the differences among hospitals.
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Affiliation(s)
- Klaus Mann
- Department of Psychiatry and Psychotherapy, University Medical Center, Untere Zahlbacher Str. 8, 55131, Mainz, Germany.
| | - Sonja Gröschel
- grid.410607.4Department of Psychiatry and Psychotherapy, University Medical Center, Untere Zahlbacher Str. 8, 55131 Mainz, Germany ,grid.410607.4Department of Neurology, University Medical Center, Mainz, Germany
| | - Susanne Singer
- grid.410607.4Department of Psychiatry and Psychotherapy, University Medical Center, Untere Zahlbacher Str. 8, 55131 Mainz, Germany ,grid.410607.4Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Mainz, Germany
| | - Jörg Breitmaier
- Department of Psychiatry and Psychotherapy, Krankenhaus Zum Guten Hirten, Ludwigshafen, Germany
| | - Sylvia Claus
- Department of Psychiatry, Psychosomatics und Psychotherapy, Pfalzklinikum, Klingenmünster, Germany
| | - Markus Fani
- Department of Geriatric Psychiatry, Psychosomatics und Psychotherapy, Pfalzklinikum, Klingenmünster, Germany
| | - Stephan Rambach
- Clinic for Psychiatry and Psychotherapy, Municipal Hospital, Pirmasens, Germany
| | - Hans-Joachim Salize
- grid.413757.30000 0004 0477 2235Central Institute of Mental Health, Medical Faculty Mannheim / Heidelberg University, Mannheim, Germany
| | - Klaus Lieb
- grid.410607.4Department of Psychiatry and Psychotherapy, University Medical Center, Untere Zahlbacher Str. 8, 55131 Mainz, Germany
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