Nurses’ knowledge, attitudes, and practices toward physical restraint and seclusion in an inpatients’ psychiatric ward

The attitudes of nurses towards seclusion: A New Zealand in-patient mental health setting

Seclusion is a form of restraint practised in mental health services world-wide, and has been criticised as unethical and traumatising to patients. Several countries have committed to reducing or eliminating seclusion. In New Zealand, there has been a focus on reducing seclusion of the indigenous Māori population, who experience particularly high rates. Nurses typically lead decisions to place patients in seclusion and their attitudes towards seclusion likely influence this process. This study aimed to address the primary question: what are the attitudes of registered nurses towards the use of seclusion? A mixed methods pragmatic approach was used involving qualitative interviews of nurses working in a high seclusion mental health ward located in the North Island of New Zealand, and a quantitative analysis of the seclusion data from this ward. This report is adherent with COREQ and STROBE. Thirteen nurses were interviewed and four main themes were identified: seclusion is necessary; seclusion is being used unnecessarily; nurse characteristics influence the use of seclusion; nurses perceived their ward culture to be improving in the use of seclusion. However, analysis of seclusion data indicated that rates had been increasing for this ward prior to this study, and the rates for indigenous Māori patients were especially elevated. This pattern of increasing rates was congruent with the 'supportive' attitudes of nurses towards seclusion. Interestingly, during the time of this study, the seclusion rates began to decline, including for Māori patients. This decline may have been partially due to the increased awareness prompted by the study.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

PATIENT AND PUBLIC CONTRIBUTION

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

Nurses' attitudes towards the use of physical restraint in psychiatric care: A systematic review of qualitative and quantitative studies

WHAT IS KNOWN ON THE SUBJECT?: Application of physical restraint is a common practice to protect service users and staff in psychiatric care. Nurses' attitudes towards physical restraint and its influencing factors in psychiatric settings in different countries are variable. Previous reviews include studies on different coercive methods, making it difficult to differentiate attitudes specific to physical restraint. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Nurses' attitudes were marked by negative feelings and moral conflict towards the use of physical restraint and consider it a necessary nursing intervention and a last resort. The barriers for restraint-free environment practice included contextual demand, lack of knowledge on restraint and lack of alternatives to restraint. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurse educators should develop and evaluate related educational training programmes to promote the development of alternative effective skills in handling violence instead of physical restraint. Policy makers should develop strategies to remove the barriers to a restraint-free environments. ABSTRACT: Introduction Physical restraint is common in psychiatric care; nurses' attitudes are crucial as nurses often implement the procedure. Previous reviews include studies exploring coercive methods but do not specifically focus on physical restraint. Aims This integrated mixed-method systematic review aimed to examine nurses' attitudes towards the use of physical restraint in psychiatric care and the factors influencing these attitudes. Methods Six databases were searched from 2000 to 2021. Thematic integrative analysis was used to synthesize the data. Results Ten studies were included. Five themes encapsulate nurses' attitudes towards physical restraint: "emotional responses," "moral conflicts," "ensuring safety for all," "a necessary nursing intervention" and "a last resort." Three themes were identified for factors influencing attitudes: "contextual demands," "level of knowledge" and "alternatives to restraint." Discussion Nurses' attitudes were marked by negative feelings and moral conflict towards the use of physical restraint. However, nurses applied physical restraint as an ordinary nursing intervention. Educational interventions and the leadership role may facilitate the change of current practice to a restraint-free environment. Implications for Practice Mental health nurses should work to remove the barriers to restraint-free environment and develop effective skills that can be used as alternatives to physical restraint.

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 New Perspective on Human Rights in the Use of Physical Restraint on Psychiatric Patients-Based on Merleau-Ponty's Phenomenology of the Body

(1) Background: Physical restraint in psychiatric settings must be determined by health care professionals for ensuring their patients’ safety. However, when a patient cannot participate in the process of deciding what occurs in their own body, can they even be considered as a personal self who lives in and experiences the lifeworld? The purpose of this study is to review the existential capability of the body from Merleau-Ponty’s phenomenology to explore ways of promoting human rights in physical restraint. (2) Methods: A philosophical reflection was contemplated regarding notions of the body’s phenomenology. (3) Results: Merleau-Ponty’s body phenomenology can explain bodily phenomena as a source of the personal subject, who perceives and acts in the world, and not as a body alienated from the subject in health and illness. Patients, when they are physically restrained, cannot be the self as a subject because their body loses its subjecthood. They are entirely objectified, becoming objects of diagnosis, protection, and control, according to the treatment principles of health care professionals. (4) Conclusions: The foundation of human rights, human being’s dignity lies in the health professionals’ genuine understanding and response to the existential crisis of the patient’s body in relation to its surrounding environment.

The Role of Implicit and Explicit Staff Attitudes in the Use of Coercive Measures in Psychiatry

Many determinants leading to the use of different coercive measures in psychiatry have been widely studied and it seems that staff attitudes play a crucial role when it comes to the decision-making process about using coercion. However, research results about staff attitudes and their role in the use of coercive measures are inconsistent. This might be due to a focus on self-report studies asking for explicit answers, which involves the risk of bias. This study aimed to expand research on this topic by examining the impact of explicit and implicit staff attitudes on the use of coercive measures in clinical practice. In addition, the influence of gender, profession (nurses, psychiatrists), and years of professional experience as well as their influence on staff attitudes were examined. An adaption of the implicit association measure, the Go/No-Go Association Task (GNAT), with the target category coercion and distracter stimuli describing work load, as well as the explicit questionnaire Staff Attitudes to Coercion Scale (SACS) was completed by staff (N = 149) on 13 acute psychiatric units in 6 hospitals. Data on coercive measures as well as the total number of treated cases for each unit was collected. Results showed that there was no association between staff's implicit and explicit attitudes toward coercion, and neither measure was correlated with the local frequency of coercive measures. ANOVAs showed a significant difference of the GNAT result for the factor gender (F = 9.32, p = 0.003), demonstrating a higher tendency to justify coercion among female staff members (M = -0.23, SD = ±0.35) compared to their male colleagues (M = -0.41, SD = ±0.31). For the SACS, a significant difference was found for the factor profession (F = 7.58, p = 0.007), with nurses (M = 2.79, SD = ±1.40) showing a more positive attitude to the use of coercion than psychiatrists (M = 2.15, SD = ±1.11). No significant associations were found regarding the extent of professional experience. Results indicate a complex interaction between implicit and explicit decision-making processes dependent on specific contexts. We propose future research to include primers for more context-related outcomes. Furthermore, differences in gender suggest a need to direct attention toward occupational safety and possible feelings of anxiety in the workplace, especially for female staff members.

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

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

A German Version of the Staff Attitude to Coercion Scale. Development and Empirical Validation

Background: Individual staff factors, such as personality traits and attitudes, are increasingly seen as an important factor in the reduction of coercion in mental health services. At the same time, only a few validated instruments exist to measure those factors and examine their influence on the use of coercion. Aim: The present study aimed to develop and validate a German version of the Staff Attitude to Coercion Scale (SACS). Methods: The original English version of the SACS published was translated into German. Subsequently, it was empirically validated on a sample of N = 209 mental health professionals by conducting an exploratory factor analysis. Results: The three-factor structure in the original version of the SACS, consisting of critical, pragmatic and positive attitudes toward the use of coercion, could not be replicated. Instead, the German version revealed one factor ranging from rejecting to approving the use of coercion. Conclusion: The SACS is one of the first instruments created to assess staff attitudes toward coercion in a validated way. The version of the instrument developed in this study allows for a validated assessment of those attitudes in German. Our results highlight the ethical importance of using validated measurements in studies on the role of staff factors in the reduction of coercion.

Psychiatric nurses' knowledge, attitudes, and practice towards the use of physical restraints

PURPOSE

This study examines the knowledge, attitudes, and practice of psychiatric nurses towards the use of physical restraint in Saudi Arabia.

DESIGN AND METHODS

Descriptive explanatory cross-sectional design, 101 participants were invited to complete a set of questionnaires to assess the knowledge, attitude, and practice towards the use of physical restraint.

FINDINGS

Participants had a moderate knowledge and attitude as well as practice in using physical restraint. Less than half reported that they recognized alternative approaches to physical restraint and most of them did not understand the reasons for the restraint.

PRACTICE IMPLICATIONS

This study highlights some important misunderstandings of nurses about using physical restraint. The findings serve as a supporting reason for recognizing the importance of educating nurses about its use.

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

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