Influence of Organizational Climate and Clinician Morale on Seclusion and Physical Restraint Use in Inpatient Psychiatric Units

Review article: Scoping review of interventions that reduce mechanical restraint in the emergency department

OBJECTIVE

Mechanical restraints are known to be associated with many undesirable outcomes in clinical settings. Our objective was to examine the current literature to explore possible interventions that would reduce the use of mechanical restraints in the ED.

METHODS

In this scoping review, we searched online databases Embase, MEDLINE and Cochrane CENTRAL for any studies published between the databases from 1 January 2007 to 19 September 2023. Studies were included if interventions were hospital- or staff-focused and reported measured outcomes before and after the introduction of the intervention. Risk of bias was assessed using the JBI Critical Appraisal Checklist for Cohort Studies.

RESULTS

The search strategy yielded 1937 studies across the three databases, of which 13 studies were extracted and included in the review. Interventions were categorised into four groups: provision of staff training, addition of a de-escalation team, creation of a dedicated unit and introduction of an agitation scale only. Most of the studies saw reduction in restraint rates or time in restraints. Only the two studies that used an agitation scale as a stand-alone intervention saw no significant reduction. Only one study had low risk of bias, whereas the remainder had high risk.

CONCLUSIONS

Evidence supports further exploration of interventions that include: designing an agitation guideline; training staff in assessment, attitudinal and de-escalation skills; addition of a crisis team; and environmental changes in the form of adding a dedicated clinical space. Although these strategies may reduce mechanical restraint in the ED setting, further high-quality studies are needed before definitive conclusions may be drawn.

Uncovering Complexities in Reducing Aggression, Conflict and Restrictive Practices in Acute Mental Healthcare Settings: An Overview of Reviews

Aggression, conflict and restrictive practices present complexities in acute mental health services, as do implementing service changes to reduce them. Existing published literature needs to offer more high-level guidance on the effectiveness of these service changes and their associated implementation factors. As a result, an overview of systematic reviews was undertaken to identify (i) nonpharmacological interventions to reduce conflict, aggression and restrictive practices in acute mental health settings, and (ii) their effects across different clinical outcomes. A parallel re-extraction from primary studies was then utilised (iii) to identify factors influencing successful intervention implementation. Of 124 articles sourced from nine databases and registries, four reviews were retained for the final analysis, using the direction of effect and tabular and narrative summaries. These reviews included programmes or interventions focused on inpatient adolescent, adult and older adult populations. They reported on alternative containment strategies, risk assessments, Safewards, sensory rooms and equipment, Six Core Strategy-based interventions and staff training. The overview found that a combination of interventions intended to improve relationships and reduce interpersonal conflict may help reduce aggression, conflict and restrictive practices. At the same time, stand-alone staff training and sensory rooms and equipment may have mixed effects. The quality of the evidence linking these interventions to reductions in aggression, conflict and restrictive practices is limited. Successful implementation hinges on multiple factors: intervention characteristics, preparation and planning, evaluation and monitoring, outcome interpretation, stakeholder involvement/investment, staff-related factors and contextual factors. Any implementation initiative may benefit from using pragmatic and complexity-informed research methodologies, including integrating meaningful involvement with service users, peer workers and culturally diverse groups.

Physical Restraint Usage in Hospitals Across the United States: 2011-2019

Objective

To determine the change in rates of physical restraint (PR) use and associated outcomes among hospitalized adults.

Patients and Methods

Using national inpatient sample databases, we analyzed years 2011-2014 and 2016-2019 to determine trends of PR usage. We also compared the years 2011-2012 and 2018-2019 to investigate rates of PR use, in-hospital mortality, length of stay, and total hospital charges.

Results

There were 242,994,110 hospitalizations during the study period. 1,538,791 (0.63%) had coding to signify PRs, compared with 241,455,319 (99.3%), which did not. From 2011 to 2014, there was a significant increase in PR use (p-trend<.01) and a nonsignificant increase in PR rates from 2016-2019 (p-trend=.07). Over time, PR use increased (2011-2012: 0.52% vs 2018-2019: 0.73%; p<.01). Patients with PRs reported a higher adjusted odds for in-hospital mortality in 2011-2012 (adjusted odds ratio [aOR], 3.9; 95% CI, 3.7-4.2; p<.01) and 2018-2019 (aOR, 3.5; 95% CI, 3.4-3.7; p<.01). Length of stay was prolonged for patients with PRs in 2011-2012 (adjusted mean difference [aMD], 4.3 days; 95% CI, 4.1-4.5; p<.01) and even longer in 2018-2019 (aMD, 5.8 days; 95% CI, 5.6-6.0; p<.01). Total hospital charges were higher for patients with PRs in 2011-2012 (aMD, +$55,003; 95% CI, $49,309-$60,679; p<.01). Following adjustment for inflation, total charges remained higher for patients with PRs compared with those without PRs in 2018-2019 (aMD, +$70,018; 95% CI, $65,355-$74,680; p<.01).

Conclusion

Overall, PR rates did not decrease across the study period, suggesting that messaging and promulgating best practice guidelines have yet to translate into a substantive change in practice patterns.

The experiences of nurses following seclusion or restraint use and immediate staff debriefing in inpatient mental health settings

AIM

The aim of this study is to explore nurses' experiences of seclusion or restraint use and their participation in immediate staff debriefing in inpatient mental health settings.

DESIGN

This research was conducted using a descriptive exploratory design and data were gathered through in-depth individual interviews.

METHODS

The experiences of nurses following seclusion or restraint use and their participation in immediate staff debriefing were explored via teleconference, using a semi-structured interview guide. Reflexive thematic analysis was used to identify prevalent themes from the data.

RESULTS

Interviews (n=10) were conducted with nurses from inpatient mental health wards in July 2020. Five themes emerged through the data analysis: (i) ensuring personal safety; (ii) grappling between the use of least-restrictive interventions and seclusion or restraint use; (iii) navigating ethical issues and personal reactions; (iv) seeking validation from colleagues and (v) attending staff debriefing based on previous experience. The themes were also analysed using Lazarus and Folkman's Transactional Model of Stress and Coping.

CONCLUSION

Staff debriefing is a vital resource for nurses to provide and/or receive emotion- and problem-focused coping strategies. Mental health institutions should strive to establish supportive working environments and develop interventions based on the unique needs of nurses and the stressors they experience following seclusion or restraint use.

PATIENT OR PUBLIC CONTRIBUTION

Nurses in both frontline and leadership roles were involved in the development and pilot test of the interview guide. The nurses who participated in the study were asked if they can be recontacted if clarification is needed during interview transcription or data analysis.

Effects of Ending the Use of Seclusion and Mechanical Restraint in the Pennsylvania State Hospital System, 2011-2020

The Pennsylvania State Hospital System's use of containment procedures has been studied for >30 years. This prospective study assessed the effects of ending the use of seclusion and mechanical restraint in the system's six civil hospitals and two forensic centers from 2011 to 2020. The study examined the effect of this change on key safety measures: physical restraint, assaults, aggression, and self-injurious behavior. In total, 68,153 incidents, including 9,518 episodes of physical restraint involving 1,811 individuals, were entered into a database along with patients' demographic and diagnostic information. All data were calculated per 1,000 days to control for census changes. During the study, mechanical restraint was used 128 times and seclusion four times. Physical restraint use decreased from a high of 2.62 uses per 1,000 days in 2013 to 2.02 in 2020. The average length of time a person was held in physical restraint was reduced by 64%, from 6.6 minutes in 2011 to 2.4 minutes in 2020 (p<0.001). All safety measures improved or were unchanged. Use of unscheduled medication did not change. The hospital system safely ended the use of mechanical restraint and seclusion by using a recovery approach and by following the six core strategies for seclusion and restraint reduction.

Clinician's experiences with involuntary commitment for substance use disorder: A qualitative study of moral distress

BACKGROUND

Petitions for involuntary commitment of people living with a substance use disorder (SUD) have almost doubled since 2011 in Massachusetts through the policy Section 35. However, the efficacy of this controversial policy remains unclear, and clinicians differ on whether it ought to be used. This study examines how clinicians decide whether to use Section 35 and their experiences of moral distress, the negative feeling that occurs when a clinician is required to pursue a treatment option against their moral judgement due to institutional constraints, associated with its use.

METHODS

Qualitative semi-structured interviews with clinicians in Massachusetts were conducted between December 2019 and February 2020 and continued until thematic saturation. Thematic and narrative analysis was conducted with recorded and transcribed interviews.

RESULTS

Among 21 clinicians, most (77%) experienced some or high moral distress when utilizing Section 35 for involuntary commitment, with clinicians working in emergency departments experiencing less distress than those working in SUD clinics. Clinicians with low moral distress referenced successful patient anecdotes and held an abstinence-based view of SUD, while clinicians with high moral distress were concerned by systemic treatment failures and understood SUD through a nuanced and harm reduction-oriented view. Clinicians across professional settings were concerned by the involvement of law enforcement and criminal justice settings in the Section 35 process. Clinicians employed a variety of strategies to cope with moral distress, including team-based decision-making and viewing the petition as a last resort. Barriers to utilizing Section 35 included restrictive court hours and lack of post-section aftercare services.

CONCLUSION

Widespread distress associated with use of involuntary commitment and inconsistent approaches to its use highlight the need for better care coordination and guidance on best practices for utilization of this policy.