Elements of successful restraint and seclusion reduction programs and their application in a large, urban, state psychiatric hospital

A Pioneer Tool to Reduce Restrictive Practices toward People with Intellectual and Developmental Disabilities

Reducing restrictive practices toward individuals with intellectual and developmental disabilities is a globally recognized imperative and human rights priority. This paper presents a novel tool called LibRe for assessing and reducing restrictive practices. This tool involved an instrumental multistage design and collaboration between professionals, individuals with disabilities, family members, and experts from different fields. It addresses diverse restrictive practices in five key domains: physical or mechanical, chemical or pharmacological, structural, relational, and practices related to contexts and supports. It addresses practices that are pertinent to the Spanish context and that existing tools have not covered. Embedded as a step within an organizational approach, LibRe fosters organizational transformation and provides resources to achieve outcomes within reduction plans for restrictive practices. In total, 156 teams comprising 585 professionals, 64 people with disabilities, and 44 family members responded to the tool. In terms of evidence for internal structure validity, the oblique five-factor model exhibited an adequate fit through confirmatory factor analysis, along with satisfactory reliability indices, according to ordinal alpha and omega. Users positively appraised the tool's usefulness and identified its strengths and challenges. Although further research is needed, preliminary evidence frames LibRe as a useful resource for practice and research.

Rural-Urban Disparities in Quality of Inpatient Psychiatric Care

OBJECTIVE

Rural residents have higher rates of serious mental illness than urban residents, but little is known about the quality of inpatient psychiatric care available to them locally or how quality may have changed in response to federal initiatives. This study aimed to examine differences and changes in the quality of inpatient psychiatric care in rural and urban hospitals.

METHODS

This national retrospective study of 1,644 facilities examined facility-level annual quality-of-care data from the Inpatient Psychiatric Facility Quality Reporting program, 2015-2019. Facility location was categorized as urban, large rural, or small or isolated rural on the basis of zip code-level rural-urban commuting area codes. Generalized regression models were used to assess rural-urban differences in care quality (five continuity-of-care and two patient experience measures) and changes over time.

RESULTS

Rural inpatient psychiatric units performed better than urban units in nearly all domains. Improvements in quality of care (excluding follow-up care) were similar in rural and urban units. Rates of 30- and 7-day postdischarge follow-up care decreased in all hospitals but faster in rural units. Timely transmission of transition records was more frequent in small or isolated rural versus urban units (mean marginal difference=22.5, 95% CI=6.3-38.8). Physical restraint or seclusion use was less likely in rural than in urban units (OR=0.6, 95% CI=0.5-0.8).

CONCLUSIONS

Rural psychiatric units had better care quality at baseline (better follow-up care, better timely transmission of transition records, and lower rates of physical restraint use) than urban units, but during 2015-2019, follow-up care performance decreased overall and more in rural than urban units.

Alternative Routes of Administration of Clozapine

Clozapine is the only antipsychotic with proven effectiveness in treatment-resistant schizophrenia. It is usually administered using commercially available oral tablets, but not all patients are willing or able to take medicines in this way. Orodispersible clozapine tablets are available from several manufacturers and may be useful where swallowing solid dosage forms is difficult, or as an aid to observe compliance. Liquid formulations of clozapine can be prepared extemporaneously or purchased commercially, but most preparations are suspensions (clozapine is poorly soluble) and patients may find them unpalatable. The administration of clozapine (suspension or crushed tablets) via enteral feeding tubes (predominantly nasogastric) has been reported both in medically unwell patients and in patients refusing clozapine. Enteral administration is likely to be superseded by intramuscular clozapine, which has recently been re-introduced and is being widely used in some countries. Successful use of this formulation in enforced treatment strategies has been described by several authors with good long-term outcomes when switched to oral treatment. Intramuscular clozapine has also been used in physically ill patients who are unable to take any form of enteral medication. Other methods of delivery (transdermal, nasal) are not yet commercially available, but offer promise of further treatment options for this group of seriously ill patients.

Clozapine re-challenge and initiation following neutropenia: a review and case series of 14 patients in a high-secure forensic hospital

OBJECTIVE

Clozapine remains the most effective intervention for treatment resistant schizophrenia; however, its use is prohibited following neutropenias. We review neutrophil biology as applied to clozapine and describe the strategies to initiate clozapine following neutropenia used in a case series of 14 consecutive patients rechallenged in a United Kingdom (UK) high-secure psychiatric hospital. We examine outcomes including the use of seclusion and transfer.

METHODS

A case series of 14 male patients with treatment resistant schizophrenia treated with clozapine despite previous episodes of neutropenia between 2006 and 2015 is presented. Data were collected during 2015 and 2019. Using this routinely collected clinical data, we describe the patient characteristics, causes of neutropenia, the strategies used for rechallenging with clozapine and clinical outcomes.

RESULTS

Previous neutropenias were the result of benign ethnic neutropenia, clozapine, other medications and autoimmune-related. Our risk mitigation strategies included: granulocyte-colony stimulating factor (G-CSF), lithium and watch-and-wait. There were no serious adverse events; at follow up half of the patient's had improved sufficiently to transfer them to conditions of lesser security. There were dramatic reductions in the use of seclusion.

CONCLUSION

Even in this extreme group, clozapine can be safely and effectively re/initiated following neutropenias, resulting in marked benefits for patients. This requires careful planning based on an understanding of neutrophil biology and the aetiology of the specific episode of neutropenia.

Evaluation of the effectiveness and acceptability of intramuscular clozapine injection: illustrative case series

AIMS AND METHOD

A series of eleven patients prescribed intramuscular clozapine at five UK sites is presented. Using routinely collected clinical data, we describe the use, efficacy and safety of this treatment modality.

RESULTS

We administered 188 doses of intramuscular clozapine to eight patients. The remaining three patients accepted oral medication. With the exception of minor injection site pain and nodules, side-effects were as expected with oral clozapine, and there were no serious untoward events. Nine patients were successfully established on oral clozapine with significant improvement in their clinical presentations.

CLINICAL IMPLICATIONS

Although a novel formulation in the UK, we have shown that intramuscular clozapine can be used safely and effectively when the oral route is initially refused.

Use of coercion prevention tools in Finnish psychiatric wards

Inpatient violence is a widespread problem in psychiatric wards and has often serious consequences. Literature indicates that de-escalation techniques are the recommended first-line intervention for managing violence, are widely used to reduce it, and restrictive practices in mental health settings. However, these techniques and models are not used at the optimum frequency and/or important factors are limiting their use and effectiveness. We aimed to determine what kind of de-escalation methods are used to reduce violence and coercion in Finnish psychiatric hospitals. Descriptive qualitative research using semi-structured questionnaires and Framework Analysis was used. The results of the study are reported in quantitative terms. A survey of psychiatric wards (N = 65) in Finland's hospital districts (n = 16) was conducted in the Autumn of 2019 to find out which de-escalation models are used. Finnish psychiatric wards use both the Safewards and Six Core Strategies models to reduce violence and the use of restrictive practices. Half of the hospitals used interventions and strategies from both models. Violence preventive methods are widely used in mental health settings in Finland. These interventions and models cover the organization, leadership, and patient perspectives to improve safety and decrease coercion actions in psychiatric wards.

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.

Socio-economic impact on involuntary admissions and coercive measures in psychiatric hospitals in Germany

OBJECTIVE

The present study aimed to characterize involuntary psychiatric admissions and coercive measures within psychiatric hospitals regarding their temporal development and processual aspects. Moreover, the influence of socio-economic factors on involuntary admissions and coercive measures was investigated.

METHODS

Different data sets from the federal state of North-Rhine Westphalia (NRW) were used in this study. In addition to a survey in which n = 33 hospitals responded (40.7%), official data from the Federal Health Ministry were analysed over a decade regarding involuntary admissions and coercive measures. These data were available for all n = 54 districts, respectively, all n = 81 psychiatric hospitals in NRW. Datasets were mainly analysed comparing different socio-economic clusters.

RESULTS

The hospital admission rate increased significantly over time (from 1.12 to 1.34 per 1000 inhabitants) within ten years. However, whereas the admission rates differed significantly between socio-economic clusters, the amount of coercive measures used in the hospitals did not. Compared to general psychiatry and addiction medicine, geriatric psychiatry had the highest amount of involuntary admissions (12.2% under public law, 14.1% under civil law). Furthermore, most coercive measures lasted at least an hour.

CONCLUSION

It seems that, despite intense discussions and enhanced efforts to reduce coercion, there are still some neglected aspects, such as the need for coercive measures and their duration, particularly in the geriatric psychiatric setting. In addition, the results show that further approaches to prevent involuntary admissions are needed to address other stakeholders beyond the hospitals and further aspects of the socio-economic environment.

Violence Factors and Debriefing in Psychiatric Inpatient Care: A Review

The aim of the current review was to identify, analyze, and synthesize the available research on violence factors in psychiatric care and the potential of debriefing to reduce the incidence of violence necessitating coercive measures. A two-part electronic search was conducted using multiple databases. Part 1 focused on reviews and meta-analyses relating to violence factors published between 2007 and 2017. Part 2 focused on articles on debriefing published after 2000. Two hundred ninety-five articles on violence factors and debriefing were identified, from which 39 publications were selected for detailed analysis. Results indicate that patient characteristics, management, staff approaches, and the ward environment are influencers that may trigger violent incidents. Several violence factors in psychiatric care have been identified. Nursing communication, leadership, and debriefing are among the most effective ways of reducing violence in psychiatric care. [Journal of Psychosocial Nursing and Mental Health Services, 58(5), 39-49.].

Measures to Avoid Coercion in Psychiatry and Their Efficacy

BACKGROUND

Coercive measures such as seclusion and restraint encroach on the patient's human rights and can have serious adverse effects ranging from emotional trauma to physical injury and even death. At the same time, they may be the only way to avert acute danger for the patient and/or the hospital staff. In this article, we provide an overview of the efficacy of the measures that have been studied to date for the avoidance of coercion in psychiatry.

METHODS

This review is based on publications retrieved by a systematic search in the Medline and Cinahl databases, supplemented by a search in the reference lists of these publications. We provide a narrative synthesis in which we categorize the interventions by content.

RESULTS

Of the 84 studies included in this review, 16 had a control group; 6 of these 16 were randomized controlled trials (RCTs). The interventions were categorized by seven different types of content: organization, staff training, risk assessment, environment, psychotherapy, debriefings, and advance directives. Most interventions in each category were found to be effective in the respective studies. 38 studies investigated complex treatment programs that incorporated elements from more than one category; 37 of these (including one RCT) revealed effective reduction of the frequency of coercion. Two RCTs on the use of rating instruments to assess the risk of aggressive behavior revealed a relative reduction of the number of seclusion measures by 27% and a reduction of the cumulative duration of seclusion by 45%.

CONCLUSION

Complex intervention programs to avoid coercive measures, incorporating elements of more than one of the above categories, seem to be particularly effective. In future, cluster-randomized trials to investigate the individual categories of intervention would be desirable.

Post-incident review after restraint in mental health care -a potential for knowledge development, recovery promotion and restraint prevention. A scoping review

Background

Use of physical restraint is a common practice in mental healthcare, but is controversial due to risk of physical and psychological harm to patients and creating ethical dilemmas for care providers. Post-incident review (PIR), that involve patient and care providers after restraints, have been deployed to prevent harm and to reduce restraint use. However, this intervention has an unclear scientific knowledge base. Thus, the aim of this scoping review was to explore the current knowledge of PIR and to assess to what extent PIR can minimize restraint-related use and harm, support care providers in handling professional and ethical dilemmas, and improve the quality of care in mental healthcare.

Methods

Systematic searches in the MEDLINE, PsychInfo, Cinahl, Sociological Abstracts and Web of Science databases were carried out. The search terms were derived from the population, intervention and settings.

Results

Twelve studies were included, six quantitative, four qualitative and two mixed methods. The studies were from Sweden, United Kingdom, Canada and United States. The studies’ design and quality varied, and PIR s’ were conducted differently. Five studies explored PIR s’ as a separate intervention after restraint use, in the other studies, PIR s’ were described as one of several components in restraint reduction programs. Outcomes seemed promising, but no significant outcome were related to using PIR alone. Patients and care providers reported PIR to: 1) be an opportunity to review restraint events, they would not have had otherwise, and 2) promote patients’ personal recovery processes, and 3) stimulate professional reflection on organizational development and care.

Conclusion

Scientific literature directly addressing PIR s’ after restraint use is lacking. However, results indicate that PIR may contribute to more professional and ethical practice regarding restraint promotion and the way restraint is executed. The practice of PIR varied, so a specific manual cannot be recommended. More research on PIR use and consequences is needed, especially PIR’s potential to contribute to restraint prevention in mental healthcare.

The assertive approach to clozapine: nasogastric administration

Aims and methodAn 'assertive approach' to clozapine, where nasogastric administration is approved, is assessed through a case-load analysis to provide the first systematic description of its use and outcomes worldwide. RESULTS: Five of the most extremely ill patients with treatment-resistant schizophrenia were established and/or maintained on clozapine, resulting in improvements to their mental state; incidents were reduced, segregation was terminated and progression to less restrictive environments was achieved.Clinical implicationsDespite being underutilised and rarely enforced, in extreme circumstances, an assertive approach to clozapine can be justified. Nasogastric clozapine can be safely delivered and the approach itself, rather than actual nasogastric administration, may be enough to help establish and maintain patients with treatment-resistant schizophrenia on the most effective treatment.Declaration of interestE.S. has received speaker fees from Jansen Pharmaceuticals and Novartis.

A case report of the successful administration of clozapine in the face of myocardial infarction, pulmonary embolism and hyperlipidaemia resulting in the termination of long-term seclusion

BACKGROUND

Cardiometabolic health significantly impacts on the mortality of people with severe mental illness. Clozapine has the greatest efficacy for Treatment Resistant Schizophrenia (TRS) but the greatest negative impact on cardiometabolic health. Balancing the risks and benefits of treatment, dignity, autonomy, liberty, mental and physical health can be challenging, particularly when imposing interventions with potentially life threatening adverse events, such as clozapine. We describe the successful administration of clozapine in the face of myocardial infarction, pulmonary embolism and hyperlipidaemia resulting in the termination of long-term seclusion for a gentleman with TRS in high secure psychiatric services.

CASE PRESENTATION

The impact of clozapine on a 44-year-old gentleman with TRS, extreme violence requiring physical restraint and long-term segregation, and numerous other significant physical health complications is described. He had metabolic syndrome; a poor diet, sedentary lifestyle, Body Mass Index (BMI) of 31.5, poorly controlled lipids and had smoked heavily since childhood. During preparations to initiate clozapine, he suffered a myocardial infarction and pulmonary embolism. His compliance with secondary prevention medications was poor due to paranoid persecutory and somatic delusions. Despite these concerns, nasogastric administration of clozapine was approved and prescribed within nine months of his myocardial infarction and a month from his pulmonary embolism but was ultimately not required. Accepting oral medication, his mental state made a rapid and dramatic improvement. After spending 1046 days in seclusion, this was terminated 94 days after clozapine initiation. He has been compliant with all medications for 24 months, had no incidents of violence or seclusion, and has been transferred to medium secure services. His physical health stabilised despite continuing to lead a sedentary lifestyle and remaining obese (BMI of 35). He developed hypertension, Type II Diabetes Mellitus and his triglycerides rose to 22.2 mmol/L in the same month after clozapine initiation. However, with pharmacological intervention, 24 months later these are controlled, and he has had no further thromboembolic events.

CONCLUSIONS

We highlight that despite significant physical health concerns, clozapine can be successfully initiated and safely prescribed with a significantly positive effect on both the psychiatric and holistic care of patients with treatment resistant schizophrenia.

Ethical dilemmas in psychiatry: When teams disagree

Many ethical dilemmas in medicine are associated with highly unusual clinical situations and are an almost daily challenge for mental health teams. We describe the ethical issues that arose in relation to a significant difference of opinion between team members about using nasogastric clozapine in the treatment of a severely ill patient. We discuss how conflicting emotions and perspectives within teams acquire ethical significance and how negotiation and reflection are essential for good-quality ethical reasoning to take place.

Learning Objectives

• Understand the different effects and importance of reasoning and emotions in moral decision-making

• Use a clinical scenario involving a difficult and controversial procedure to explore the impact of social persuasion in moral decision-making

• Consider the effects of heuristics against rational thinking

Multidimensional approach to restraint minimization: The journey of a specialized mental health organization

The executive-level witnessing and review of restraint events has been identified as a key strategy for restraint minimization. In the present study, we examined the changes in restraint practices at a tertiary-level mental health-care facility with implementation of an initiative, in which representatives from senior management, professional practice, peer support, and clinical ethics witnessed seclusion and restraint events, and rounded with clinical teams to discuss timely release and brainstorm prevention strategies. Interrupted time series analysis compared the change from pre-implementation (14 months prior) to postimplementation (35 months' following) in the number of incidents/month, total hours/month, and average hours/incident/month for each of seclusion and mechanical restraint. With implementation, there was a step decrease in average hours/seclusion (-28.3 hours/seclusion, P < 0.001) and total seclusion hours (-1264.5 hours, P = 0.002). The postimplementation rate of decrease of -0.9 hours/incident/month was different than the pre-implementation rate of increase of 0.7 hours/incident/month for mechanical restraint (P = 0.03). Pre-implementation, there was a rate of decrease of 6.1 incidents/month (P < 0.001) and 4.5 incidents/month (P = 0.001) for seclusion and mechanical restraint, respectively. Postimplementation, there was a rate of increase of 0.3 incidents/month and a rate of decrease of 0.05 incidents/month for seclusion and mechanical restraint, respectively, both of which were different than pre-implementation (seclusion: P < 0.001, mechanical restraint: P = 0.002). In conclusion, the total hours of seclusion and average hours per seclusion and per restraint incident were reduced, demonstrating the value of leadership witnessing and daily rounds in promoting restraint minimization in tertiary-level mental health care.

Workplace Violence Toward Mental Healthcare Workers Employed in Psychiatric Wards

Background

Workplace violence (WPV) against healthcare workers (HCWs) employed in psychiatric inpatient wards is a serious occupational issue that involves both staff and patients; the consequences of WPV may include increased service costs and lower standards of care. The purpose of this review was to evaluate which topics have been focused on in the literature and which are new in approaching the concern of patient violence against HCWs employed in psychiatric inpatient wards, in the past 20 years.

Methods

We searched for publications in PubMed and Web of Science using selected keywords. Each article was reviewed and categorized into one or more of the following four categories based on its subject matter: risk assessment, risk management, occurrence rates, and physical/nonphysical consequences.

Results

Our search resulted in a total of 64 publications that matched our inclusion criteria. The topics discussed, in order of frequency (from highest to lowest), were as follows: “risk assessment,” “risk management,” “occurrence rates,” and “physical/nonphysical consequences.” Schizophrenia, young age, alcohol use, drug misuse, a history of violence, and hostile-dominant interpersonal styles were found to be the predictors of patients’ violence.

Conclusion

Risk assessment of violence by patients appeared the way to effectively minimize the occurrence of WPV and, consequently, to better protect mental HCWs. We found paucity of data regarding psychologic sequelae of WPV. According to these findings, we suggest the need to better investigate the psychologic consequences of WPV, with the aim of checking the effective interventions to assist HCW victims of violence and to prevent psychologic illness.

Mental Health Nursing, Mechanical Restraint Measures and Patients' Legal Rights

Coercive mechanical restraint (MR) in psychiatry constitutes the perhaps most extensive exception from the common health law requirement for involving patients in health care decisions and achieving their informed consent prior to treatment. Coercive measures and particularly MR seriously collide with patient autonomy principles, pose a particular challenge to psychiatric patients' legal rights, and put intensified demands on health professional performance. Legal rights principles require rationale for coercive measure use be thoroughly considered and rigorously documented. This article presents an in-principle Danish Psychiatric Complaint Board decision concerning MR use initiated by untrained staff. The case illustrates that, judicially, weight must be put on the patient perspective on course of happenings and especially when health professional documentation is scant, patients' rights call for taking notice of patient evaluations. Consequently, if it comes out that psychiatric staff failed to pay appropriate consideration for the patient's mental state, perspective, and expressions, patient response deviations are to be judicially interpreted in this light potentially rendering MR use illegitimated. While specification of law criteria might possibly improve law use and promote patients' rights, education of psychiatry professionals must address the need for, as far as possible, paying due regard to meeting patient perspectives and participation principles as well as formal law and documentation requirements.

Post-Seclusion and/or Restraint Review in Psychiatry: A Scoping Review

CONTEXT

It has been suggested that after an incident in which a patient has been placed in seclusion or in restraints, an intervention should be conducted after the event to ensure continuity of care and prevent recurrences. Several terms are used, and various models have been suggested for post-seclusion and/or restraint review; however, the intervention has never been precisely defined.

OBJECTIVE

This article presents a scoping review on post-seclusion and/or restraint review in psychiatry to examine existing models and the theoretical foundations on which they rely.

METHOD

A scoping review of academic articles (CINAHL and Medline database) yielded 28 articles.

RESULTS

Post-seclusion and/or restraint review has its origins in the concepts of debriefing in psychology and reflective practice in nursing. We propose a typology in terms of the intervention target, including the patient, the health care providers, or both.

IMPLICATIONS

The analysis found that the review ought to involve both the patient and the care providers using an approach that fosters reflexivity among all those involved in order to change the practice of seclusion in psychiatric settings.

ACCESSIBLE SUMMARY

• Established literature documented widely that seclusion and restraint has adverse physical and psychological consequences for patient and for health care providers. • Post-seclusion and/or restraint review is promoted in most guidelines, but there is no scoping or systematic review yet on the subject. • The origins of post-seclusion and/or restraint review are in the concepts of debriefing in psychology and reflective practice in nursing. • We propose that post-seclusion and/or restraint review should focus on both patients and health care providers.• Systematic post-seclusion and/or restraint review should be performed after each event, and its effects on patients and on mental health professionals should be rigorously assessed.

Effects of a Regulatory Protocol for Mechanical Restraint and Coercion in a Spanish Psychiatric Ward

PURPOSE

There is still limited information on what type of measures are most efficient to reduce coercion. The aim of this study was to determine if the introduction of a new regulatory protocol in a specific psychiatric ward in Andalusia (Spain) contributed to reducing the use of mechanical restraint.

DESIGN AND METHODS

The study included a comparison of two time periods: 2005 (one year before the implementation of the new regulatory protocol) and 2012, in all hospitalized patients (N=1,094). The study also analyzes with logistic regression the variables related to a shorter duration of mechanical restraint.

FINDINGS

Mechanical restraint rate per year was reduced, not significantly, from 18.2% to 15.1%. The average duration of each mechanical restraint episode was significantly reduced from 27.91 to 15.33 hr. The following variables have been associated with a shorter period of coercion: being female and the year of restraint (2012).

PRACTICE IMPLICATIONS

Specific plans are required, including different interventions, in order to achieve marked reduction in the use of coercive measures.

Prevalence and Risk Factors of Violence by Psychiatric Acute Inpatients: A Systematic Review and Meta-Analysis

Background

Violence in acute psychiatric wards affects the safety of other patients and the effectiveness of treatment. However, there is a wide variation in reported rates of violence in acute psychiatric wards.

Objectives

To use meta-analysis to estimate the pooled rate of violence in published studies, and examine the characteristics of the participants, and aspects of the studies themselves that might explain the variation in the reported rates of violence (moderators).

Method

Systematic meta-analysis of studies published between January 1995 and December 2014, which reported rates of violence in acute psychiatric wards of general or psychiatric hospitals in high-income countries.

Results

Of the 23,972 inpatients described in 35 studies, the pooled proportion of patients who committed at least one act of violence was 17% (95% confidence interval (CI) 14–20%). Studies with higher proportions of male patients, involuntary patients, patients with schizophrenia and patients with alcohol use disorder reported higher rates of inpatient violence.

Conclusion

The findings of this study suggest that almost 1 in 5 patients admitted to acute psychiatric units may commit an act of violence. Factors associated with levels of violence in psychiatric units are similar to factors that are associated with violence among individual patients (male gender, diagnosis of schizophrenia, substance use and lifetime history of violence).

The methodical work approach and the reduction in the use of seclusion: how did it work?

The prevention of seclusion and other coercive measures has become a priority for mental health facilities, and numerous comprehensive programs to reduce the use of these containment procedures, have been developed. It is, however, poorly understood which interventions or elements of programs are effective and by which mechanisms or processes change is mediated. The present study explores the effects of an intervention by which a reduction in the use of seclusion was achieved. The intervention concerned a transformation of the treatment process, based on the principles of the methodical work approach, at a ward for the intensive treatment of patients with psychosis and substance use disorders. Changes in the working practice and team process were analyzed on the basis of case examples and team evaluation. The methodical work approach appears to have provided a guidance for the multidisciplinary team, the patient and the family to work together in a systematic and goal-directed way with cyclic evaluation and readjustment of the treatment and nurse care plan. Also implicit, positive changes were found in the team process: increased interdisciplinary collaboration, team cohesion, and professionalization. It is argued that the implicit or non-specific effects of an intervention to prevent seclusion may constitute a major contribution to the results and therefore merit further research.

Five-year review of absconding in three acute psychiatric inpatient wards in Australia

Absconding, where patients under an involuntary mental health order leave hospital without permission, can result in patient harm and emotional and professional implications for nursing staff. However, Australian data to drive nursing interventions remain sparse. The purpose of this retrospective study was to investigate absconding in three acute care wards from January 2006 to June 2010, in order to determine absconding rates, compare patients who did and did not abscond, and to examine incidents. The absconding rate was 17.22 incidents per 100 involuntary admissions (12.09% of patients), with no significant change over time. Being male, young, diagnosed with a schizophrenia or substance-use disorder, and having a longer hospital stay were predictive of absconding. Aboriginal and Torres Strait Islander patients had higher odds of absconding than Caucasian Australians. Over 25% of absconding patients did so multiple times. Patients absconded early in admission. More incidents occurred earlier in the year, during summer and autumn, and later in the week, and few incidents occurred early in the morning. Almost 60% of incidents lasted ≤24 hours. Formulation of prospective interventions considering population demographic factors and person-specific concerns are required for evidence-based nursing management of the risks of absconding and effective incident handling when they do occur.

Reducing the use of seclusion in a secure service for women

Reducing the use of seclusion to deal with challenging behaviour is a priority in secure services for women. This study describes the concurrent introduction of a series of initiatives based on recovery principles and the full involvement of patients in their risk management plans.

Following change implementation, the first 19 patients who had completed one year of treatment were matched with 19 patients who had completed their first year of treatment before change.

A significant decline in both the number of seclusions and risk behaviour post-change was complemented by improved staff ratings of institutional behaviour, increased treatment engagement and a reduction in time spent in medium security. Staff and patients differed in terms of their ratings of the most effective strategies introduced. Patients favoured the Relational Security item of increased individual engagement and timetabled Behaviour Chain Analysis sessions. Staff viewed on ward training and use of de-escalation techniques as most effective.

Findings confirm results from mixed gender forensic mental health samples that seclusion can be successfully reduced without an increase in patient violence or alternative coercive strategies. Limitations of the study are discussed along with the need for future evaluations to address issues of fidelity and utilise vigorously designed case studies.

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.

Restraint use in acute and extended mental health services for older persons

Restraint of older persons in inpatient and residential care is used to control aggression, and prevent falls and other adverse outcomes. Initiatives to reduce these practices are being implemented worldwide. However, there has been little examination of restraint practice in psychiatric services for older persons. This paper reports a retrospective comparative analysis of restraint use in three acute and two extended care psychiatric inpatient wards in Australia. The analysis involved examination of restraint incidents and comparison of restrained and non-restrained patients. There was significant variation in restraint use between wards. On one acute ward, 12.74% of patients were restrained, although restraint use declined during the data collection period. Patients with dementia were restrained at higher rates than patients with other diagnoses, and restrained patients stayed in hospital for a longer duration. Restraint occurred early in admission, and few differences emerged between those restrained once or multiple times. Mechanical restraint was more prevalent than physical restraint, with restraint predominantly used to manage aggression and falls. Findings provide new data on restraint in older persons' psychiatric services. Greater conceptual understandings of behaviours associated with dementia and the unique needs of patients with these disorders may assist in reducing restraint use in these settings.

The developmental and social history of repetitively aggressive mental health patients

OBJECTIVE

A small subgroup of patients is primarily responsible for the large number of aggressive and violent incidents in psychiatric inpatient units. This study aims to identify the developmental, social and interpersonal histories of repeatedly aggressive patients in order to better understand their treatment needs.

METHODS

A total of 1269 consecutive inpatients were studied over 18 months, identifying 64 who were repeatedly aggressive; 128 non-aggressive patients were randomly matched to the aggressive patients by age, sex and diagnosis. Developmental, social, interpersonal and familial histories were obtained from a chart review.

RESULTS

Repeatedly aggressive patients were significantly more likely to have had a history of aggression, physical and sexual abuse, and experienced interpersonal problems and parental divorce.

CONCLUSIONS

Aggressive patients do not just need short-term skills training, but interventions that target interpersonal and personality disorder deficits associated with their developmental histories.

Professionals' attitudes after a seclusion reduction program: anything changed?

Changing professionals' attitudes toward seclusion is seen as an important condition to reduce its use. The purpose of this study was to determine whether professionals from a mental health institute in the Netherlands changed in their attitudes toward seclusion after implementation of a multifaceted seclusion reduction program. Professionals working on four acute admission wards filled in the Professional Attitudes Toward Seclusion Questionnaire (PATS-Q) before and after a seclusion reduction program. Changes were analyzed by comparing mean scores on the PATS-Q. After the program, professionals scored significantly higher on 'ethics' and 'more care'. As expected, no change occurred on 'reasons' for the use of seclusion. In addition, no significant changes were found on 'confidence', 'better care' and 'other care'. Significant changes in professional attitudes concerning the ethics of using seclusion and involving issues of more care were observed after a seclusion reduction program. Mental health professionals moved in the direction of 'transformers', indicating an increased criticism of the practice of seclusion and increased willingness to change their own use of seclusion.

Differences in seclusion rates between admission wards: does patient compilation explain?

Comparison of seclusion figures between wards in Dutch psychiatric hospitals showed substantial differences in number and duration of seclusions. In the opinion of nurses and ward managers, these differences may predominantly be explained by differences in patient characteristics, as these are expected to have a large impact on these seclusion rates. Nurses assume more admissions of severely ill patients are related to higher seclusion rates. In order to test this hypothesis, we investigated differences in patient and background characteristics of 718 secluded patients over 5,097 admissions on 29 different admission wards over seven Dutch psychiatric hospitals. We performed an extreme group analysis to explore the relationship between patient and ward characteristics and the wards' number of seclusion hours per 1,000 admission hours. In a multivariate and a multilevel analysis, various characteristics turned out to be related to the number of seclusion hours per 1,000 admission hours as well as to the likelihood of a patient being secluded, confirming the nurses assumptions. The extreme group analysis showed that seclusion rates depended on both patient and ward characteristics. A multivariate and multilevel analyses revealed that differences in seclusion hours between wards could partially be explained by ward size next to patient characteristics. However, the largest deal of the difference between wards in seclusion rates could not be explained by characteristics measured in this study. We concluded ward policy and adequate staffing may, in particular on smaller wards, be key issues in reduction of seclusion.

Early detection of risk factors for seclusion and restraint: a prospective study

AIM

The study aims to examine the predictive power of static and dynamic risk factors assessed at admission to an acute psychiatric ward and to develop a prediction model evaluating the risk of seclusion and restraint.

METHODS

Over 20 months, data on demographic and clinical characteristics, psychosocial functioning, level of insight, uncooperativeness, and use of coercive measures were collected prospectively on 520 patients at admission. Logistic regression analysis was used to develop a prediction model. The magnitude of the predictive power of this model was estimated using receiver operating characteristic analysis.

RESULTS

The prediction model contained one static predictor (involuntary commitment) and two dynamic predictors (psychological impairment and uncooperativeness), with a high predictive power (receiver operating characteristic area under the curve = 0.83). The final risk model classified 72% of the patients correctly, with a higher sensitivity rate (80%) than specificity rate (71%).

CONCLUSION

Early assessment of patients' psychological impairment and uncooperativeness can help clinicians to recognize patients at risk for coercive measures and approach them on time with preventive and less restrictive interventions. Although this simple, highly predictive model accurately predicts the risk of seclusion or restraint, further validation studies are needed before it can be adopted into routine clinical practice.

Mechanical restraint--which interventions prevent episodes of mechanical restraint?- a systematic review

PURPOSE

To identify interventions preventing mechanical restraints.

DESIGN AND METHODS

Systematic review of international research papers dealing with mechanical restraint. The review combines qualitative and quantitative research in a new way, describing the quality of evidence and the effect of intervention.

FINDINGS

Implementation of cognitive milieu therapy, combined interventions, and patient-centered care were the three interventions most likely to reduce the number of mechanical restraints.

PRACTICE IMPLICATIONS

There is a lack of high-quality and effective intervention studies. This leaves patients and metal health professionals with uncertainty when choosing interventions in an attempt to prevent mechanical restraints.

Methodological issues in monitoring the use of coercive measures

PURPOSE

In many European countries, initiatives have emerged to reduce the use of seclusion and restraint in psychiatric institutions. To study the effects of these initiatives at a national and international level, consensus on definitions of coercive measures, assessment methods and calculation procedures of these coercive measures are required. The aim of this article is to identify problems in defining and recording coercive measures. The study contributes to the development of consistent comparable measurements definitions and provides recommendations for meaningful data-analyses illustrating the relevance of the proposed framework.

METHODS

Relevant literature was reviewed to identify various definitions and calculation modalities used to measure coercive measures in psychiatric inpatient care. Figures on the coercive measures and epidemiological ratios were calculated in a standardized way. To illustrate how research in clinical practice on coercive measures can be conducted, data from a large multicenter study on seclusion patterns in the Netherlands were used.

RESULTS

Twelve Dutch mental health institutes serving a population of 6.57 million inhabitants provided their comprehensive coercion measure data sets. In total 37 hospitals and 227 wards containing 6812 beds were included in the study. Overall seclusion and restraint data in a sample of 31,594 admissions in 20,934 patients were analyzed. Considerable variation in ward and patient characteristics was identified in this study. The chance to be exposed to seclusion per capita inhabitants of the institute's catchment areas varied between 0.31 and 1.6 per 100.000. Between mental health institutions, the duration in seclusion hours per 1000 inpatient hours varied from less than 1 up to 18h. The number of seclusion incidents per 1000 admissions varied between 79 up to 745. The mean duration of seclusion incidents of nearly 184h may be seen as high in an international perspective.

CONCLUSION

Coercive measures can be reliably assessed in a standardized and comparable way under the condition of using clear joint definitions. Methodological consensus between researchers and mental health professionals on these definitions is necessary to allow comparisons of seclusion and restraint rates. The study contributes to the development of international standards on gathering coercion related data and the consistent calculation of relevant outcome parameters.

Exploring patterns of seclusion use in Australian mental health services

Seclusion has remained a common practice in mental health services. In Australia, recent mental health policy has reflected a desire to reduce (and, if possible, eliminate) the use of seclusion. The collection and analysis of data on the use of seclusion have been identified as an important component of the success of reduction initiatives. A cross-sectional design was used in the collection of inpatient unit data on seclusions that occurred in 11 mental health services in Australia over a 6-month period. During this time, there were 4,337 episodes of care. One or more seclusions occurred in 6.8% of episodes of care, with consumers being secluded, on average, 2.32 times and with 44% of them having been secluded more than once. The average length of the seclusions was 2 hours 52 minutes, with 51.4% of seclusions being less than 2 hours. These rates were lower than those reported in previous research studies. The practice of seclusion occurred more commonly on the first 2 days following admission, on weekdays than weekends, and between the hours of 9:00 a.m. and midnight. An understanding of seclusion data can provide fundamental information from which strategies to reduce seclusion can be developed.

Frequency of assault and severity of injury of psychiatric nurses in relation to the nurses' decision to restrain

Ethical standards and current law demand that acute care psychiatric patients be treated with respect, using the least restrictive interventions. Unfortunately, as restraint use has decreased, assault and injury of mental health care workers has increased. Violence against those working in acute care psychiatry is a serious global issue that needs further examination. This study provides current, in depth information about the nature, frequency and severity of assaults and injuries of psychiatric nurses. This study also examined assault and injury in relation to the nurse's decision to restrain. The findings of this study were compared with findings of an earlier study carried out by one of the authors (Moylan) prior to the institution of policies, which are more restrictive in the use of restraint. In a sample of 110 nurses from five institutions, 80% of the nurses were assaulted, 65% had been injured and 26% had been seriously injured. Injuries included fractures, eye injuries and permanent disability. The number and severity of injuries have increased significantly since the 1996 study. Nurses who had been injured decided to restrain later in the progression of aggression than those who had not been injured.

Reducing seclusion and restraint: questionnaire for organizational assessment

Mental health organizations that have successfully reduced or, in some cases, eliminated use of seclusion and restraint report that they have primarily focused on organizational factors to facilitate this process. The purpose of this paper is to describe the development of an instrument that measures staff perceptions of organizational activities to reduce seclusion and restraint as well as staff attitudes toward the use of these interventions. Consequently, the instrument can be used diagnostically to identify areas in need of improvement and can also be used as an outcome measure to assess shifts in staff perceptions reflective of organizational change. This article describes validation of the instrument, information on its administration, and analysis and use of data obtained with it.

Interventions to reduce the use of seclusion and restraint in inpatient psychiatric settings: what we know so far a review of the literature

INTRODUCTION

In recent times, much attention has been focused on the reduction of seclusion and restraint in psychiatric settings. This paper analyzes evidence available from evaluations of single seclusion and/or restraint reduction programmes. A total of 29 papers were included in the review.

RESULTS

Seven key strategy types emerged from the analysis: (i) policy change/leadership; (ii) external review/debriefing; (iii) data use; (iv) training; (v) consumer/family involvement; (vi) increase in staff ratio/crisis response teams; and (vii) programme elements/changes. Outcomes indicate that a range of reduction programmes are successful in reducing the frequency and duration of seclusion and restraint use, while at the same time maintaining a safe environment.

CONCLUSION

The development of new seclusion and restraint reduction programmes should include strong leadership from local management; external seclusion and restraint review committees or post-incident debriefing and analysis; broad-based staff training and programme changes at a local level. Behavioural and cognitive-behavioural programmes appear to be very useful in child and adolescent services. Further systematic research should be conducted to more fully understand which elements of successful programmes are the most powerful in reducing incidents of seclusion and restraint.

Post-seclusion debriefing: a core nursing intervention

PURPOSE

The purpose of this study was to investigate the frequency and type of post-seclusion debriefing provided by nurses at a psychiatric unit in Melbourne, Australia.

DESIGN AND METHODS

The study employed an exploratory research design. An analysis of the seclusion register was undertaken to identify the total number of seclusions over a 1-year period. A file audit tool was developed to identify seclusion debriefing interventions documented in consumer case files.

FINDINGS

Post-seclusion debriefing is not routinely performed following an episode of seclusion.

PRACTICE IMPLICATIONS

A post-seclusion debriefing framework needs to be developed to support best practice in managing seclusion.

A review of interventions to reduce mechanical restraint and seclusion among adult psychiatric inpatients

This review examines the nature and effectiveness of interventions to reduce the use of mechanical restraint and seclusion among adult psychiatric inpatients. Thirty-six post-1960 empirical studies were identified. The interventions were diverse, but commonly included new restraint or seclusion policies, staffing changes, staff training, case review procedures, or crisis management initiatives. Most studies reported reduced levels of mechanical restraint and/or seclusion, but the standard of evidence was poor. The research did not address which programme components were most successful. More attention should be paid to understanding how interventions work, particularly from the perspective of nursing staff, an issue that is largely overlooked.

The role of the inpatient psychiatric nurse and its effect on job satisfaction

This study recorded the amount of time 73 nurses working on inpatient psychiatric units spent on specific functions during a shift. The nurses also rated the amount of time they actually spent on the functions versus the amount of time they ideally would like to spend. Nurses spent only 2.18 minutes per shift teaching symptom management, and close to 2 hours on paperwork. Correlations between time spent in specific functions and job satisfaction indicate that nurses who spent more time with direct patient care were more satisfied. The results offer insight for increasing job satisfaction and retention/recruitment efforts.

Violence and restraint reduction efforts on inpatient psychiatric units

Efforts to reduce aggression and violence and the use of restraint and seclusion have traditionally been through some form of educational program. This paper presents an integrative review of research and quality improvement projects that aimed to reduce aggression/violence or restraint/seclusion through the use of an educational program. Forty-six papers are included in this review. This paper presents summaries and comparisons of the research designs, the content and length of programs, and the outcomes of these programs. From these summaries, trends in relation to design, content, and outcomes are identified, and recommendations for clinicians and researchers are given.

Reflection on the use of seclusion: in an acute mental health facility

This pilot study provides a snapshot of the use of seclusion within an acute care mental health unit in Queensland, Australia. The study collected baseline data against which practice reform aimed at reducing its use could be gauged. A mixed methodology was adopted, undertaking retrospective chart reviews, collecting qualitative survey data from individual nursing staff (n = 71) and patients (n = 4), and conducting focus groups to identify factors contributing to seclusion use. The study revealed a local facility seclusion rate of 12% compared with a national average of 10%. The re-seclusion rate of 76% was significantly higher than the national average of 31%. Eighty-seven percent of seclusion episodes were longer than 4 hours, compared with a national average of 41%. In approximately one third of cases, the required documentation was incomplete. Consumers mostly perceived seclusion as punishing and nontherapeutic, in contrast to staff, who generally viewed it as appropriate and potentially therapeutic.

A narrative review of the effectiveness of aggression management training programs for psychiatric hospital staff

Workplace violence, including patient-perpetrated violence in healthcare settings, is increasingly being recognized as preventable. Staff training has been identified as a necessary component of any initiative aimed at preventing or reducing incidents of aggression and violence in the workplace. This narrative review of the literature evaluates the effectiveness of staff training programs designed to prevent and manage violence and aggression in psychiatric hospitals. An exhaustive review of the literature was performed on all articles published in English between January 1, 1990 and April 1, 2007 that evaluate an aggression management training program. Twenty-nine studies met the inclusion criteria for a full review and were summarized using a qualitative narrative approach. Aggression management training has been proven effective in some areas, such as reducing the use of restraints and other coercive control devices, but more methodologically rigorous research is needed to firmly establish whether it is effective in reducing aggression and staff injuries.

IMPLICATIONS

The findings of this study suggest that relying too heavily on aggression management staff training will have limited effect on addressing the range of issues related to patient-perpetrated violence in psychiatric hospitals. Mental healthcare organizations must look beyond staff training if they are to achieve meaningful reductions in aggressive incidents and staff injuries.

Professionals' attitudes toward reducing restraint: the case of seclusion in the Netherlands

INTRODUCTION

Despite public opinion and policy interventions, restraint remains a common practice. This is also the case in the Netherlands, where projects aimed to reduce seclusion, have not led to a decreased use of restraint. Is this lack of effectiveness related to attitudes of the professionals? The aim of this study was to explore the attitudes of professionals working in mental health care toward restraint.

METHOD

A questionnaire with eight scales was constructed for measuring attitudes of professionals. Scores of 540 professionals were studied, using analysis of variance and cluster analysis and related to several personnel and organizational characteristics.

RESULTS

The more professionals were personally involved in seclusion, the more they believed in it. Three types of professionals were identified: Transformers, Doubters and Maintainers. More than half of the psychiatrists (56%) belonged to the type of maintainers. Nurses were more divided.

CONCLUSION

Professionals working in clinical settings are not really opposed to restraint. This could explain the limited effects of innovation projects.

Reducing patient restraints: a pilot approach using clinical case review

PURPOSE

This study aims to reduce the incidents of restraints by applying a nontraditional consultation process in which a university-based team focused on patient consultations to collect data on treatment interventions and milieu approaches and conditions, as well as staff interactions.

CONCLUSIONS

The efforts resulted in restraint reduction from 36 episodes per month to 0 episodes per month as well as precipitating a change in unit climate and care approaches on a specialized unit for patients with developmental disabilities and mental illness.

PRACTICE IMPLICATIONS

Reducing the use of restraints involving multiple restraint incident patients is possible with a team-based approach and a specific intervention plan.

Enhancing patient safety in psychiatric settings

OBJECTIVE

There is growing national consensus that use of institutional measures of control, such as seclusion, restraint, enforced medications, and hand-cuffed transport, within psychiatric hospitals is all too common and is potentially counter-therapeutic. Unfortunately, little is known about how to reduce such measures of last resort. This article reviews the available literature and describes a proposed research agenda involving a behavioral effort, the Engagement Model, for reducing seclusion and restraint procedures and enhancing patient safety in psychiatric settings.

METHODS

Using Medline and PsychInfo, we reviewed studies that specifically evaluated efforts to reduce seclusion and restraint on psychiatric units. Key search terms included seclusion, restraint, reduc*, psychiatric patient safety, psychiatric safety, psychiatric sanctuary, and quality of care psychiatry.

RESULTS

Only very limited data are available on reducing measures of last resort and improving the safety of psychiatric settings, and virtually no controlled data are available concerning the effectiveness of specific behavioral efforts on subsequent reduction of seclusion and restraint events. In light of the paucity of data, we describe efforts to incorporate and evaluate such a model in a large academic psychiatric hospital using a multiple baseline times-series design and review principles for and obstacles to implementing this model.

CONCLUSIONS

It is hoped this discussion will stimulate research on this understudied topic and provide a framework for improving patient safety in psychiatric settings.

Interventions for reducing the use of seclusion in psychiatric facilities: review of the literature

BACKGROUND

The authors of a recent systematic review concluded that the use of non-pharmacological containment methods, excluding restraint and seclusion, was not supported by evidence. Their focus on randomised, controlled trials, however, does not reflect the research that has been, or could be, conducted.

AIMS

To find empirically supported interventions that allow reduction in the use of seclusion in psychiatric facilities.

METHOD

We reviewed English-language, peer-reviewed literature on interventions that allow reduction in the use of seclusion.

RESULTS

Staff typically used multiple interventions, including state-level support, state policy and regulation changes, leadership, examinations of the practice contexts, staff integration, treatment plan improvement, increased staff to patient ratios, monitoring seclusion episodes, psychiatric emergency response teams, staff education, monitoring of patients, pharmacological interventions, treating patients as active participants in seclusion reduction interventions, changing the therapeutic environment, changing the facility environment, adopting a facility focus, and improving staff safety and welfare.

CONCLUSIONS

Reducing seclusion rates is challenging and generally requires staff to implement several interventions.