As time goes by: reasons and characteristics of prolonged episodes of mechanical restraint in forensic psychiatry

Mental health patients' preferences regarding restrictive interventions: An integrative review

WHAT IS KNOWN ON THE SUBJECT?: The use of restrictive interventions is described as a violation of patients' rights and autonomy. It must only be used as a last resort to manage dangerous behaviour, to prevent or reduce the risk of mental health patients harming themselves or others. International mental health policy and legislation agree that when restrictive interventions are applied, the least restrictive alternative should be chosen. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The results are ambiguous, as to which restrictive intervention is preferred over others, but there are tendencies towards the majority preferring observation, with mechanical restraint being the least preferred. To make the experience less intrusive and restrictive, certain factors are preferred, such as a more pleasant and humane seclusion room environment, staff communicating during the application and staff of same gender applying the intervention. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: When applying restrictive interventions, mental health professionals should consider environment, communication and duration factors that influence patient preferences, such as the opportunity to keep some personal items in the seclusion room, or, when using restraint, to communicate the reason and explain what is going to happen. More research is needed to clarify patients' preferences regarding restrictive interventions and their views on which are the least restrictive. Preferably, agreement is needed on standard measures, and global use of the same definition of restrictive interventions.

ABSTRACT

INTRODUCTION: The use of restrictive interventions is a violation of patients' rights that causes physical and psychological harm and which is a well-known challenge globally. Mental health law and legislative principles and experts agree that when restrictive interventions are applied, the least restrictive alternative should be used. However, there is no consensus on what is the least restrictive alternative, especially from the patient perspective.

AIM

To investigate the literature on mental health patients' preferences regarding restrictive interventions applied during admission to a psychiatric hospital.

METHOD

An integrative review informed by the PRISMA statement and thematic analysis were undertaken.

RESULTS

There were tendencies towards patients preferring observation and, for the majority, mechanical restraint was the least preferred restrictive intervention. Factors such as environment, communication and duration were found to influence patients' preferences.

DISCUSSION

There is a lack of agreement on how best to measure patients' preferences and this complicates the choice of the least restrictive alternative. Nonetheless, our findings show that staff should consider environment, communication and duration when applying restrictive interventions.

IMPLICATIONS FOR PRACTICE

More research on restrictive interventions and the least restrictive alternative is warranted, but agreement is needed on standard measures, and a standard global definition of restrictive interventions.

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.

Abolition of coercion in mental health services - A European survey of feasibility

BACKGROUND

In 2019, the Council of Europe agreed to urge member states to take steps toward total abolition of psychiatric coercive measures.

AIMS

To test if this aspiration is perceived as realistic and what the alternative would be in the event of a total abolition, we surveyed members of the European FOSTREN network of mental health practitioners and researchers, which is specifically dedicated to exchanging knowledge on reducing psychiatric coercion to its minimum.

METHODS

Web-based survey. Categorical responses were analyzed using frequencies, and free text responses were analyzed through thematic analysis.

RESULTS

In total, out of 167 invitations to FOSTREN network members, 76 responded to the survey (Response Rate 45.5%). A minority (31%) of participating experts dedicated to the reduction of psychiatric coercive measures believed a total abolition to be an achievable goal. A commonly held belief was that total abolition is not achievable because mental health disorders are difficult to treat and may cause violence, necessitating coercion, and there is a need to protect the involved persons from harm. Those responding that complete abolition is achievable argued that the consequences of coercion outweigh any gains and indicated that use of advance directives are sufficient as alternatives to coercion.

CONCLUSION

Of a European group of experts specifically dedicated to the reduction of psychiatric coercion who participated in this questionnaire study, a minority believed a total abolition be an achievable goal. The study adds to the empirical evidence of the feasibility of the aspiration to totally abolish involuntary measures in the mental health services from the perspective of experts.

Scientific models for qualitative research: a textual thematic analysis coding system - Part 1

BACKGROUND

Models are central to the acquisition and organisation of scientific knowledge. However, there are few explanations of how to develop models in qualitative research, particularly in terms of thematic analysis.

AIM

To describe a new technique for scientific qualitative modelling: the Empirical Testing Thematic Analysis (ETTA). Part 2 describes the ETTA model.

DISCUSSION

ETTA generates a semantic structure expressed through theme-code, content and functionality. It highlights the importance of authenticity markings and taxonomical and functional semantic analysis. Its primary advantage is the sequential need to account for taxonomic analysis, functionality factors, preconditioning items, cascade directories and modulation factors; this results in the production of a sound, systematic, scientific development of a model.

CONCLUSION

ETTA is useful for nurse researchers undertaking qualitative research who want to construct models derived from their investigations.

IMPLICATIONS FOR PRACTICE

This article provides a step-by-step approach for researchers undertaking research that culminates in the construction of a model derived from qualitative investigations.

Factors associated with prolonged episodes of mechanical restraint in mental health hospitalization units in Andalusia

WHAT IS KNOWN ON THE SUBJECT?: Risk factors associated with prolonged episodes of mechanical restraint and other coercive measures are understudied. There have been no studies of this phenomenon in the context of the Andalusian public health system. Knowledge about factors associated with prolonged episodes is essential to increase the understanding of this phenomenon and develop strategies to reduce its occurrence. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: In Andalusia, prolonged restraint is still frequent and varies depending on the unit. It is associated with less time since admission, male gender, diagnosis, reason for restraint and the shift on which it was initiated. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Interventions at the level of the units could be necessary to prevent prolonged episodes of mechanical restraint. The results suggest the need for stricter control during the shifts on which restraint starts, especially in the first days after the patient's admission. Preventive risk assessment considering clinical and sociodemographic risk factors could help to reduce prolonged restraint. ABSTRACT: Introduction Factors associated with prolonged episodes of mechanical restraint and other coercive interventions are not clearly established and have been not studied in Andalusia (Spain). Aim To study factors associated with prolonged episodes of mechanical restraint. Method We analysed retrospectively episodes of mechanical restraint (N = 6267, prolonged episode >9.5 hours) in all public mental health hospitalization units (N = 20, 535 beds) that offer health coverage for the autonomous community of Andalusia. The data came from clinical records. A multivariable mixed logistic regression was used. Results In Andalusia, prolonged restraint is still frequent and varies depending on the unit. It is associated with less time since admission, male gender, diagnosis, reason for restraint and the shift on which it was initiated. Discussion The results provide evidence that prolonged episodes largely depend on the unit where they occur and that stricter control and regulation are necessary to prevent prolonged episodes. Implications for practice Interventions at the level of the unit are necessary. Stricter control in the shifts during which there is more risk of prolonged restraint may be necessary, especially in the first days following admission.

Abjection and the weaponization of bodily excretions in forensic psychiatry settings: A poststructural reflection

Nurses working in forensic psychiatric settings face unique challenges in practice, where they take on a dual role of custody and caring. Patient resistance is widespread within these restrictive settings and can take many forms. Perhaps the most disturbing form of resistance entails a patient's weaponization of their bodily fluids, with nurses as their target. The tendency in assigning motive for this act is to relegate to the psychopathology of the patient. This paper will adopt a poststructuralist perspective to reexamine this phenomenon as an act of resistance through the lens of Kristeva's concept of abjection. Patients confined in these settings have little sense of control, and in resistance may resort to the only thing available: their bodily fluids. By weaponizing the abject, patients actively violate and permeate the physical and psychological boundaries of nurses-the very boundaries considered crucial to safe and professional forensic psychiatric nursing practice. By recognizing this phenomenon as an act of resistance to confinement and loss of control, nurses may reorient their approach to care in forensic psychiatric settings.

Determinants of mechanical restraint in an acute psychiatric care unit

BACKGROUND

Despite numerous attempts to reduce the use of mechanical restraint (MR), this technique continues to be widely applied in many acute psychiatric care settings. In order to reduce MR, a better understanding of the variables associated with its use and duration in different clinical environments is essential.

AIM

To determine the proportion of patients subjected to MR and the duration thereof in two acute care psychiatric units; and to identify the variables associated with the use and duration of MR.

METHODS

Descriptive study of all patients admitted to the acute psychiatric units at the Parc de Salut Mar (Barcelona, Spain) in the year 2018. The number and percentage of patients subjected to MR, as well as the duration of each episode were assessed. The following data were also registered: sociodemographic characteristics, psychiatric diagnosis, and presence of cultural and/or language barriers. Multivariate analyses were performed to assess determinants of MR and its duration.

RESULTS

Of the 464 patients, 119 (25.6%) required MR, with a median of 16.4 h per MR. Two factors - a diagnosis of psychotic disorder [Odds ratios (OR) = 0.22; 95%CI: 0.06-0.62; P = 0.005] and the presence of a language barrier (OR = 2.13; 95%CI: 1.2-3.7; P = 0.007) - were associated with a significantly higher risk of MR. Male sex was associated with a longer duration of MR (B = -19.03; 95%CI: -38.06-0.008; P = 0.05).

CONCLUSION

The presence of a language barrier and a psychotic disorder diagnosis are associated with a significantly higher risk of MR. Furthermore, male sex is associated with a longer duration of MR. Individualized restraint protocols that include the required tools are necessary to ultimately limit the use of mechanical restraint.

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

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

Construct validity of the Mechanical Restraint - Confounders, Risk, Alliance Score (MR-CRAS): a new risk assessment instrument

Background: A new short-term risk assessment instrument, the Mechanical Restraint - Confounders, Risk, Alliance Score (MR - CRAS) checklist, including three subscales with altogether 18 items, has been developed in close collaboration with forensic mental health nurses, psychiatrists' etc., and shows evidence of being comprehensible, relevant, comprehensive and easy to use for assessing the patient's readiness to be released from mechanical restraint. Aim: The aim of this study was to investigate whether the subscales: confounders, risk and parameters of alliance constituted separate subscales and needed further revisions. Materials and methods: MR - CRAS was field-study tested among nurses, nurse assistants and social and health care assistants in 13 Danish closed forensic mental health inpatient units, and a Mokken analysis of scalability and a Spearman correlation analysis were performed. Results: MR - CRAS was completed by clinicians in 143 episodes of mechanical restraint, representing 88 patients, with a mean duration of 63.25 hours. Most patients were younger men, diagnosed within the schizophrenia spectrum. One-third of the patients had repeated mechanical restraint episodes ranging between 2 and 8 episodes. MR - CRAS and especially the parameters of alliance were perceived as usable for assessment of the patient's readiness to be released from mechanical restraint. The psychometric analyses showed that the three subscales were unidimensional. Conclusions: The study shows evidence of the construct validity of MR - CRAS among clinicians at closed forensic mental health inpatient units. MR - CRAS contributes with a common language and structured, systematic and transparent observations and assessments on an hour by hour basis during mechanical restraint.

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

AIM

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

BACKGROUND

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPACT

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

A Matter of Trust and Distrust: A Qualitative Investigation of Parents' Perceptions About the Use of Mechanical Restraint on Their Adult Children in a Forensic Psychiatric Setting

INTRODUCTION

Increased knowledge about forensic psychiatric patients' relatives' perceptions in regard to the use of mechanical restraint (MR) is necessary, if clinical practice is to be improved and to achieve a reduction in the use and frequency of MR. However, a specific knowledge deficit about relatives' perspectives on the use of MR limits the evidence base considerably.

AIM

The aim of this study was to investigate the perceptions of MR held by relatives of forensic psychiatric patients' including factors impacting its use and duration.

METHOD

Qualitative interviews were conducted with 15 parents of patients within a forensic psychiatry setting and thematically analyzed.

FINDINGS

Two main themes were identified, namely, "care and protection" and "inclusion and involvement," and one subtheme, "information." These themes revealed the framework used by parents to construct a sense of "trust or distrust" about the ability of staff to provide adequate and safe care for their adult children in the forensic psychiatric setting.

CONCLUSION

Some parents in this study considered that forensic psychiatric staff used MR as a necessary protection. However, most parents held strong negative perceptions regarding the use of MR and the quality and safety of care provision. It is apparent that parents in this study believed they should be included and involved in the care in situations associated with the use of MR, because they considered that this could reduce its use. Further research is required to target interventions to reduce the use and duration of MR episodes and to improve clinical practice in forensic psychiatry.

Forensic psychiatric patients' perceptions of situations associated with mechanical restraint: A qualitative interview study

To reduce the use and duration of mechanical restraint in forensic settings and ensure evidence-based patient care, we need more knowledge about patients' subjective experiences and perceptions. The aim was to investigate forensic psychiatric patients' perceptions of situations associated with the use of mechanical restraint and what they perceive as factors impacting the use and duration of mechanical restraint. Twenty participants were interviewed. Four themes were identified through a thematic analysis: 'overt protest reactions', 'silent protest reactions', 'illness-related behaviour', and 'genuinely calm', which together characterize patients' perceptions of their ways of acting and reacting during mechanical restraint episodes. These themes are linked together in two patterns in the process of mechanical restraint: 'pattern of protest' and 'pattern of illness'. Further research is needed to illuminate the associations between patients' perceptions of being subjected to mechanical restraint and ways of acting and reacting through the process of mechanical restraint.

Dual diagnosis and mechanical restraint - a register based study of 31,793 patients and 6562 episodes of mechanical restraint in the Capital region of Denmark from 2010-2014

OBJECTIVE

To investigate whether patients with dual diagnosis have a higher risk of being mechanical restraint compared to patients with only psychiatric diagnoses.

METHODS

Data on all patients admitted to a psychiatric ward from 2010-2014 in the Capital Region of Denmark was linked with information from the register of coercive measures. Patients were based on diagnosis divided into six groups. The three main patient groups were: only psychiatric diagnosis defined as all ICD-10 F-diagnosis except F10-F19, dual diagnosis (co-occurrence of diagnoses of harmful use or dependency and psychiatric diagnoses) and only other substance use diagnosis (i.e. other than harmful use or dependency). The risk of mechanical restraint was investigated by analyzing all first-time admissions in the period using Cox-proportional hazard models.

RESULTS

In the crude rates patients with dual diagnosis were more often mechanically restrained compared to patients with only psychiatric diagnoses or only other substance use diagnoses. However, this was attenuated when the characteristics of patients were accounted for. Patients with only other substance related diagnoses had the highest risk of being mechanically restrained.

CONCLUSION

When preventing mechanical restraint, the focus should be on actual use of substances or withdrawal effects and not on the dual diagnoses patients in them-self.

Management of Violence and Aggression in Emergency Environment; a Narrative Review of 200 Related Articles

CONTEXT

The aim of this study is to reviewing various approaches for dealing with agitated patients in emergency department (ED) including of chemical and physical restraint methods.

EVIDENCE ACQUISITION

This review was conducted by searching "Violence," "Aggression," and "workplace violence" keywords in these databases: PubMed, Scopus, EmBase, ScienceDirect, Cochrane Database, and Google Scholar. In addition to using keywords for finding the papers, the related article capability was used to find more papers. From the found papers, published papers from 2005 to 2018 were chosen to enter the paper pool for further review.

RESULTS

Ultimately, 200 papers were used in this paper to conduct a comprehensive review regarding violence management in ED. The results were categorized as prevention, verbal methods, pharmacological interventions and physical restraint.

CONCLUSION

In this study various methods of chemical and physical restraint methods were reviewed so an emergency medicine physician be aware of various available choices in different clinical situations for agitated patients.

Effect of Complex Working Conditions on Nurses Who Exert Coercive Measures in Forensic Psychiatric Care

Nurses who exert coercive measures on patients within psychiatric care are emotionally affected. However, research on their working conditions and environment is limited. The purpose of the current study was to describe nurses' experiences and thoughts concerning the exertion of coercive measures in forensic psychiatric care. The investigation was a qualitative interview study using unstructured interviews; data were analyzed with inductive content analysis. Results described participants' thoughts and experiences of coercive measures from four main categories: (a) acting against the patients' will, (b) reasoning about ethical justifications, (c) feelings of compassion, and (d) the need for debriefing. The current study illuminates the working conditions of nurses who exert coercive measures in clinical practice with patients who have a long-term relationship with severe symptomatology. The findings are important to further discuss how nurses and leaders can promote a healthier working environment. [Journal of Psychosocial Nursing and Mental Health Services, 54(9), 37-43.].

Forensic mental health clinician's experiences with and assessment of alliance regarding the patient's readiness to be released from mechanical restraint

One of the main reasons for prolonged duration of mechanical restraint is patient behaviour in relation to the clinician-patient alliance. This article reports on the forensic mental health clinicians experiences of the clinician-patient alliance during mechanical restraint, and their assessment of parameters of alliance regarding the patient's readiness to be released from restraint. We used a qualitative, descriptive approach and conducted focus group interviews with nurses, nurse assistants and social and healthcare assistants. The results show that a pre-established personal clinician-patient alliance formed the basis for entering into, and weighing the quality of, the alliance during mechanical restraint. In consideration of the patient's psychiatric condition, the clinicians observed and assessed two quality parameters for the alliance: 'the patient's insight into or understanding of present situation' (e.g. the reasons for mechanical restraint and the behaviour required of the patient to discontinue restraint) and 'the patient's ability to have good and stable contact and cooperation with and across clinicians. These assessments were included, as a total picture of the quality of the alliance with the patient', in the overall team assessment of the patient's readiness to be released from mechanical restraint. The results contribute to inform the development of a short-term risk assessment instrument, with the aim of reducing the duration of mechanical restraint.

Feeling Safe and Taking on Responsibilities: Newly Graduated Nurses' Perceptions and Evaluations of Their Transition Into a Forensic Mental Health Inpatient Setting

Forensic mental health care is faced with serious problems in the recruitment and retention of newly graduated nurses (NGNs). Research into NGNs' experiences of their transition to and evaluations of transition programs in forensic care is sparse, and more studies are called for. This study aimed to investigate the characteristics of NGNs' experiences and perceptions of their transition into a forensic setting and their evaluations of the introduction period. Three focus group interviews were carried out, involving 13 NGNs, lasting 79.68 minutes on average. They were analyzed using thematic analysis. Results show two main themes: "feeling safe" and "taking on responsibilities." If NGNs felt overburdened with clinical responsibilities during their transition, their feeling of safety reduced. The converse also applied; theThe safer they felt, the greater clinical responsibility they felt capable of handling. The more difficult the NGNs perceived the informal transition, the more unsafe they felt, and the more negatively they perceived the responsibilities placed upon them. Tailored programs designed to support both the informal and formal transitions are recommended, along with preceptorship, theoretical training, and role-based support, such as a shift manager, along with early introduction to conflict management and security measures.

"Treat me with respect". A systematic review and thematic analysis of psychiatric patients' reported perceptions of the situations associated with the process of coercion

WHAT IS KNOWN ON THE SUBJECT?: Psychiatric patients have generally negative experiences of being exposed to coercive measures. Existing research has generally not investigated coercion as a process; that is, it does not address issues that arise before, during and after exposure to coercion. A part of existing research within the area does not clarify and define the type of coercive measure(s) investigated. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Patients place great significance on the link between the positive and negative perceived impact of a coercive situation and the professionals' ability and willingness to interact and communicate respectfully. Psychiatric patients associate the use of seclusion, physical restraint/holding, mechanical restraint and forced medication with strong negative perceptions and wish to be treated with respect by professionals, rather than being subjected to the professionals' control. What patients perceive as moderating factors in regard to the use of coercive measures is currently under-researched. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Increased sensitivity to the patient's views of the situation at each point in the coercive process would help professionals to respond to the patients' individual needs. Professionals need to articulate concern and empathy towards patients and to improve communication skills before, during and after a coercive incident. Greater emphasis should be placed on de-escalation and the use of non-coercive strategies or coping skills before the initiation of coercive measures.

ABSTRACT

Introduction There is a lack of research into psychiatric patients' perceptions of coercion that discriminates between different types of coercive measures, while also investigating patients' perceptions of undergoing coercion as a process. This knowledge is required to improve our understanding and provide a foundation for improving clinical practice. Aims To review existing research literature in order to investigate adult psychiatric patients' reported perceptions of situations before, during and after specific and defined types of coercive measures, and to investigate what patients perceive as moderating factors, in regard to the use of these coercive measures. Method A systematic review and thematic analysis of 26 peer-reviewed studies was undertaken. Results The analysis identified six themes and additional subthemes, where "interactions with professionals" and "communication" were predominant themes across the timeline of coercion. Altogether, themes were associated with either "positive or negative patient-perceived impact." Implications for practice Increased sensitivity to patients' views of the situation at each point in the process is desirable in order to respond to the patients' individual needs. Professionals also need to articulate concern and empathy towards the patient and to improve communication skills before, during and after a coercive incident. Use of de-escalation and noncoercive strategies is required. Relevance statement Coercion within psychiatric/mental health care remains controversial, and repeated international calls have recommended a reduction of their use. This review indicates that greater attention to how patients perceive the use of coercive measures (before, during, and after incidents) needs to be considered in order to improve the evidence-based and clinical practice.

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

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

'Mechanical restraint-confounders, risk, alliance score': testing the clinical validity of a new risk assessment instrument

BACKGROUND

Unstructured risk assessment, as well as confounders (underlying reasons for the patient's risk behaviour and alliance), risk behaviour, and parameters of alliance, have been identified as factors that prolong the duration of mechanical restraint among forensic mental health inpatients.

AIM

To clinically validate a new, structured short-term risk assessment instrument called the Mechanical Restraint-Confounders, Risk, Alliance Score (MR-CRAS), with the intended purpose of supporting the clinicians' observation and assessment of the patient's readiness to be released from mechanical restraint.

METHODS

The content and layout of MR-CRAS and its user manual were evaluated using face validation by forensic mental health clinicians, content validation by an expert panel, and pilot testing within two, closed forensic mental health inpatient units.

RESULTS

The three sub-scales (Confounders, Risk, and a parameter of Alliance) showed excellent content validity. The clinical validations also showed that MR-CRAS was perceived and experienced as a comprehensible, relevant, comprehensive, and useable risk assessment instrument.

CONCLUSIONS

MR-CRAS contains 18 clinically valid items, and the instrument can be used to support the clinical decision-making regarding the possibility of releasing the patient from mechanical restraint.

IMPLICATIONS

The present three studies have clinically validated a short MR-CRAS scale that is currently being psychometrically tested in a larger study.

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.