'I sang Amazing Grace for about 3 hours that day': understanding Indigenous Australians' experience of seclusion

Experiences of restrictive interventions in psychiatric health care from the perspectives of patients and health care professionals: Meta-synthesis of qualitative evidence

WHAT IS KNOWN ON THE SUBJECT

Following their experience, patients with physical restraints often experienced traumatic sensations. The experiences of healthcare professionals' (HCPs') are primarily concerned with moral distress or conflicts between loyalty to the treatment and oppression of the patient's freedom when implementing RIs.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

Improving the competency of HCPs can help establish therapeutic relationships rooted in compassionate care and facilitate appropriate assessments to determine whether and how often RIs are necessary. Furthermore, fostering an environment that guarantees patient safety and dignity, assuring a sufficient staffing ratio, and providing opportunities to share RI experiences can help improve the quality of care and build safe environments for RIs.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

Effective interaction between HCPs and patients, thorough patient assessment, and compassionate patient care may improve competency of HCPs intervene RIs procedures. Creating a safe therapeutic environment, including improvements to structural environments, increasing the staff-to-patient ratio, establishing organizational policies that guarantee staff debriefing, provide emotional support, provide appropriate training programs to HCPs to their coping skills during RIs also reduce the use of RIs and improve the quality of mental health care.

ABSTRACT

INTRODUCTION: Restrictive interventions (RIs) are used in psychiatric inpatient units for ensuring safety. However, few studies have comprehensively reviewed physical restraint and seclusion experiences from the perspectives of both patients and healthcare professionals' (HCPs'). This study aims to gain an in-depth understanding of the RI experiences of mental health inpatients and HCPs.

METHODS

A meta-synthesis was undertaken of qualitative studies exploring the RI experiences. Five electronic databases were searched and additional manual searches were performed for studies published within the last decade. Twelve articles were included, and a thematic analysis was conducted. The Critical Appraisal Skills Program (CASP) checklist was used to assess data quality.

FINDINGS

Two main subthemes were identified: 'Competency of HCPs' (three subthemes: interaction between patients and HCPs, assessment methods, and care) and 'systems' (three subthemes: environment, protocols with training, and debriefing), including both positive and negative experiences.

DISCUSSION

The Competency of HCPs and the ward environment are critical factors related to patients' unmet needs. Effective interactions between HCPs and patients, thorough patient assessments, and compassionate patient care are important elements of RI implementation.

CONCLUSION

An environment that guarantees safety and care with dignity, sufficient staffing ratios, and opportunities to share RI experiences may improve quality of care and create safe environments for RIs.

Seclusion within the first 24 h following admission into inpatient mental health services and associations with referral pathways, recent service contact and HoNOS ratings

WHAT IS KNOWN ON THE SUBJECT?: Seclusion is a harmful and traumatising intervention for people accessing mental health services. People who are subject to seclusion in inpatient mental health services often first experience this within the first 24 h following admission. There is limited research examining how recent contact with services impacts the likelihood of seclusion when people are admitted to inpatient services. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Males, Māori and Pasifika experience higher rates of seclusion within the first 24 h following inpatient admission. People perceived by clinicians as overactive, aggressive, disruptive or agitated are seven times more likely to be secluded within the first 24 h. People referred from police or justice services are three times more likely to be secluded within the first 24 h. People who had frequent contact with community mental health services prior to inpatient admission were less likely to be secluded. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The first 24 h of inpatient admission is a critical focus for eliminating the use of seclusion. Initial interactions with people recently admitted should focus on nurturing relationships and reducing distress. Mental health staff should consider the person's cultural needs, referral pathway, recent service contact and baseline ratings on the Health of the Nation Outcomes Scales (HoNOS) when working proactively to prevent the use of seclusion in the first 24 h following admission. Strengthening the focus on nurturing relationships, cultural understanding and non-coercive de-escalation approaches requires leadership support and strategic workforce development. ABSTRACT: Introduction People who experience seclusion in inpatient mental health services often do so within the first 24 h following admission. There is limited research examining the potential contributing factors, particularly recent contact with services. Aim/Question To identify factors associated with seclusion within the first 24 h following admission into acute inpatient mental health services. Method A retrospective analysis was undertaken using routinely collected data from Aotearoa New Zealand mental health services. Results A higher likelihood of seclusion within the first 24 h following admission was associated with: males, Māori, Pasifika, referrals from police/justice services, inpatient transfers, recent contact with crisis assessment teams and clinician perceptions of aggression, problematic substance use, cognitive problems and hallucinations or delusions. Recent contact with community mental health services was associated with a lower likelihood. Discussion People's cultural needs, referral pathway, recent service contact and HoNOS scores should be considered when working to prevent the use of seclusion in the first 24 h following admission. Implications for Practice The first 24 h following inpatient admission is a critical period for preventing the use of seclusion. Nurturing relationships, cultural understanding and use of non-coercive de-escalation approaches can support better outcomes for people recently admitted.

Staff perspectives on the effects of seclusion in adolescent psychiatric inpatient care

Nurses are at the forefront of seclusion in adolescent psychiatric units. Understanding nurses and other staff perspectives on the effects of seclusion is critical in the ongoing effort to minimize and eliminate seclusion. The aim of this study was to gain a better understanding of staff attitudes, experiences, and beliefs about the effects of seclusion on both themselves and patients. Thirty-one staff members (including 20 nurses) completed the Attitudes to Seclusion Survey and 24 participated in semi-structured interviews to explore their beliefs and experiences of seclusion use in adolescent psychiatric inpatient care. Analysis of the questionnaire showed overwhelming agreement in the negative impacts of seclusion on patients, while there was uncertainty around the positive impacts of seclusion. Using a combination of the intuitive approach and thematic analysis, five themes were identified from interviews with staff, three unique to nurses: (i) staff were reluctant to use seclusion but felt it was necessary, (ii) nurses felt under-resourcing led to increased chances of seclusion, (iii) staff believed seclusion negatively impacted the patients, (iv) nurses felt their relationships with patients were negatively impacted, and (v) seclusion also had a negative effect on nurses. Clinical recommendations included a systematic and structured approach to debriefing to repair ruptures in the therapeutic relationship; staffing to be based on the acuity of the unit rather than occupancy; alternatives to seclusion that meet the needs of service providers and consumers. Future research should compare staff and patient perspectives, include multiple sites, and greater participation of non-nursing staff.

A systematic review of client’s perspectives on the cultural and racial awareness and responsiveness of mental health practitioners

Culturally and racially responsive practice continues to be a common challenge among Mental Health Practitioners (MHPs). To the authors’ knowledge, this systematic review was the first to collate and synthesize clients’ perspectives of MHPs’ cultural and racial awareness and responsiveness from around the world. Original studies that were published between 2010 and 2021 reporting on qualitative data about clients’ perspectives regarding MHPs’ cultural-racial awareness and responsiveness were included in the review. The studies’ key findings that addressed this review’s question were synthesized and analyzed using reflexive thematic analysis. This review found 48 papers that met inclusion criteria, which represented the views of 652 clients across 10 countries. Three major themes and eight subthemes were established that concerned characteristics of the MHP, the client, and the therapeutic alliance. The results of this review indicate individual and systemic factors that influence mental health access for people from culturally and racially marginalized groups. Ongoing training of MHPs, increased racial and cultural representation among MHPs, inclusive physical settings, and reduced discrimination by MHPs are among the key findings and directions based on the results of this review.

A qualitative synthesis of patients' experiences of re-traumatization in acute mental health inpatient settings

WHAT IS KNOWN ON THE SUBJECT?: Research indicates many people accessing mental healthcare have trauma history and often experience re-traumatization in acute mental health inpatient settings. Treatment for trauma is not routinely explored as a treatment option in mental health inpatient settings and consequently mental health professionals do not draw connections between the person with trauma history and their presenting mental health problems. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: People in acute mental health inpatient units are not asked about their previous trauma histories on admission and their trauma history is not taken into consideration during interventions in particular coercive practices such as seclusion, restraint, forced medication, and involuntary admission. This paper provides an understanding on how to address trauma-related issues within in-patient settings and identifies practical examples of how to reduce the risk of re-traumatization. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Staff induction and training development needs can be used to help mental health professionals to be more confident and competent in assessing and identifying the history of trauma so that they can improve recognition, provide post-disclosure support, and avoid the potential for re-traumatization for inpatients. Physical environments need to be welcoming, homely, and have comfortable furnishing. They also require adequate space for inpatients to move around freely and have a quiet space to go to de-escalate themselves when required.

ABSTRACT

INTRODUCTION: Rates of re-traumatization among mentally ill-health patients have risen significantly over the past decade and clinical guidelines place mental health nurses at the heart of their care.

AIM

To gather, analyse, and synthesize the evidence on people's experiences on re-traumatization in acute mental health inpatient settings.

METHOD

A systematic search for qualitative studies (CINAHL, MEDLINE, ASSIA, PsycINFO, and EMBASE) was conducted. Two authors independently assessed eligibility and appraised methodological quality using Joanna Briggs's quality appraisal tool and extracted data. The analysis followed the principles of interpretative synthesis.

RESULTS

Fourteen papers were included for thematic synthesis. Three themes emerged: (1) Quality of staff interaction; (2) Specific interventions, (Sub-theme nature of symptoms); and (3) Nature of the environment.

DISCUSSION

Our findings demonstrate that patients are experiencing re-traumatization in acute mental health inpatient settings and that there is little being done to prevent it from occurring.

IMPLICATIONS FOR PRACTICE

This study is the first to analyse the factors that contribute to re-traumatization and make recommendations to mental healthcare professionals to reduce the harmful practices in place in inpatient settings. It is suggested that training staff in trauma-informed care and allowing patients to be experts in their own care can reduce the rates of re-traumatization.

Ethnic disparities in the use of restrictive practices in adult mental health inpatient settings: a scoping review

PURPOSE

To identify and summarise extant knowledge about patient ethnicity and the use of various types of restrictive practices in adult mental health inpatient settings.

METHODS

A scoping review methodological framework recommended by the JBI was used. A systematic search was conducted in APA PsycINFO, CINAHL with Full Text, Embase, PubMed and Scopus. Additionally, grey literature searches were conducted in Google, OpenGrey and selected websites, and the reference lists of included studies were explored.

RESULTS

Altogether, 38 studies were included: 34 were primary studies; 4, reviews. The geographical settings were as follows: Europe (n = 26), Western Pacific (n = 8), Americas (n = 3) and South-East Asia (n = 1). In primary studies, ethnicity was reported according to migrant/national status (n = 16), mixed categories (n = 12), indigenous vs. non-indigenous (n = 5), region of origin (n = 1), sub-categories of indigenous people (n = 1) and religion (n = 1). In reviews, ethnicity was not comparable. The categories of restrictive practices included seclusion, which was widely reported across the studies (n = 20), multiple restrictive practices studied concurrently (n = 17), mechanical restraint (n = 8), rapid tranquillisation (n = 7) and manual restraint (n = 1).

CONCLUSIONS

Ethnic disparities in restrictive practice use in adult mental health inpatient settings has received some scholarly attention. Evidence suggests that certain ethnic minorities were more likely to experience restrictive practices than other groups. However, extant research was characterised by a lack of consensus and continuity. Furthermore, widely different definitions of ethnicity and restrictive practices were used, which hampers researchers' and clinicians' understanding of the issue. Further research in this field may improve mental health practice.

Clarifying Cultural Safety: its focus and intent in an Australian context

The nursing/midwifery professions are facing a sea change with the inclusion of cultural safety in the Code of Conduct for Registered Nurses (NMBA 2018a), the Code of Conduct for Midwives (NMBA 2018b), the Registered Nurse Accreditation Standards (Australian Nursing and Midwifery Accreditation Council [ANMAC] 2019) and the Midwife Accreditation Standards (ANMAC 2021). In this paper we focus on the theme of enabling cultural safety seeking to overcome the barrier of confusion surrounding it. The inclusion of cultural safety in codes and accreditation standards, highlights the pressing need for these professions to attain deep understanding of cultural safety so that clinicians and educators can confidently practice and teach in this area. This need is underscored by the context of heightened awareness, that developed amongst mainstream Australians with Black Lives Matter in 2020, of inequity including health inequity.Our concern as academics responsible for staff development, curriculum development and implementation in university Schools of Nursing/Midwifery is to enable and support the teaching and practice of cultural safety. Its focus on working in partnership, addressing power imbalances, racisms, and related systems of discrimination constitutes it as a vastly different model to cultural other-awareness and notions of cultural competency which have held sway on matters of culture in health service provision up to now. Our approach was to undertake a reflection on our combined decades of studying, leadership, teaching and practice of cultural safety, which consistently showed the confusion in Australia about the model overall and about the definition of culture underpinning it. This paper supports the profession by addressing the need to educate academics and clinicians on cultural safety itself and on the role of all nurses/midwives, Indigenous and non-Indigenous, in these endeavours. This paper encourages a coherent development and confident implementation of cultural safety curriculum and practice to meet current requirements.

Mental health nursing practice and Aboriginal and Torres Strait Islander people: an integrative review

Background: For nearly thirty years, significant concerns have been raised about the public-provided mental health services for Aboriginal and Torres Strait Islander peoples. Staff have been identified as having little understanding of Indigenous culture, and this had resulted in inappropriate treatment. In attempting to understand what specialist knowledge exists to guide mental health nursing practice with Aboriginal and Torres Strait Islander peoples, the authors have turned to published peer-reviewed literature.Methods: The approach chosen to explore this area was an integrative review. This provided a method to identify, analyse, and synthesise a wide range of literature.Results: The available evidence points to the need that treatment planning must be focused on the promotion of social and emotional wellbeing and not simply the treatment of symptoms. It also emphasises the importance of cultural safety informed by awareness and understanding of social, cultural and historical factors that can impact the health and treatment of Aboriginal and Torres Strait Islander peoples. Within the literature, staff reported difficulty in understanding how knowledge about social and emotional wellbeing could translate into practice. Nurses working in mental health contexts reported not feeling adequately prepared for, or confident in this area of practice.Conclusions: There is a paucity of current literature on mental health nursing practice for Aboriginal and Torres Strait Islander peoples, with the literature available not providing clear guidance for effective and meaningful practice.

Seclusion: A Patient Perspective

The appropriate treatment of mentally unwell, aggressive patients has challenged psychiatry for centuries. Seclusion is practiced worldwide, but concerns remain regarding its appropriateness and lack of alternatives. Patients generally report seclusion as a negative experience, though there is a paucity of literature exploring this in detail. This investigation was a service evaluation appraising inpatients' perspective of processes occurring before (information, communication), during (review, care), and after (debrief, reflection) seclusion in a psychiatric intensive care unit (PICU). In this phenomenological study, qualitative data were gathered using a questionnaire in a structured interview. All patients had been nursed in seclusion during admission to a male PICU at South London and the Maudsley NHS Foundation Trust. Ten patients were interviewed over 4 months. The central theme was perceived lack of communication in the patient-professional relationship, which manifested itself as (i) violence against patients, (ii) lack of psychological support, and (iii) the need for alternatives. Such feedback from patients queries whether national guidelines are appropriate and/or being adhered to. Healthcare practitioners have a responsibility to challenge accepted practice to continually improve the standard of patient-centred care. Utilising patient perspectives can be a powerful driver of change towards more humane treatment of vulnerable patients.

Being in a Seclusion Room: The Forensic Psychiatric Inpatients' Perspective

WHAT IS KNOWN ON THE SUBJECT

Existing qualitative research has found inpatient service users to experience seclusion as highly distressing, with feelings of vulnerability, abuse and neglect often featuring in participants' accounts. The physical environment of the seclusion room and the interaction with clinical staff shape service users' personal seclusion experience.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

The majority of research on this topic focuses on seclusion within other restrictive practices. This paper provides new knowledge on one specific component of seclusion, the experience of being in the room, and draws attention to the specific psychological needs of service users during that aspect of their experience. This research provides new knowledge by exclusively exploring forensic inpatients' experience of the seclusion room, an under researched and often stigmatized population.

WHAT ARE THE IMPLICATIONS TO PRACTICE

The findings support the need for a caring and non-threatening therapeutic interaction with a secluded service user for the duration of time they are in the seclusion room. The findings suggest that necessary nursing procedures, such as observations, should be carried out discretely and sensitively to avoid service users feeling abused and frightened.

ABSTRACT

Introduction Contemporary qualitative research has explored service users' experience of seclusion and has found it to be a highly distressing and potentially traumatizing experience for service users. The majority of the existing literature has researched seclusion within the context of other restrictive practices, resulting in findings that can only be considered an overview of the experience. The studies also rarely access participants with histories of considerable violence and imprisonment. Question What is forensic psychiatric inpatients' experience of being in a seclusion room? Method Seven inpatients in a medium secure hospital were interviewed, and interpretative phenomenological analysis (IPA) was used to analyse the data. Results Four superordinate themes were identified: "intense fear," 'not getting the care I needed," 'I am being abused" and "power struggle." Discussion While participants were in the seclusion room, they experienced extreme fear. Staff interaction played a considerable role in shaping the participants' experience. Staff actions were interpreted as neglectful and abusive. Participants experienced struggling for power with staff, seeking out power when left in a powerless position. Implications for practice These findings suggested that a carefully tailored therapeutic interaction is required during seclusion in order to safeguard the mental health of forensic inpatients.

System Entrapment: Dehumanization While Help-Seeking for Suicidality in Women Who Have Experienced Intimate Partner Violence

Attention to power imbalances when seeking help for suicidality after having been controlled within intimate partner violence (IPV) is crucial in improving health care delivery. Well documented in the literature is the correlation between suicidality and IPV and that help-seeking for each is difficult; however, a gap exists when both intersect. The process of women's help-seeking is explored in this feminist grounded theory and photovoice multiple qualitative method study. Analysis of interviews with 32 women from New Brunswick, Canada, and photovoice meetings with seven women revealed a basic psycho-social problem. System Entrapment or being dehumanized while seeking help for suicidality occurred as a result of perceived invalidation from health care providers' lack of empathy. Further harm while providing services to women feeling suicidal can be prevented with a shift from an individualist model toward a trauma and violence informed approach. Understanding the contextual factors influencing women's suicidality may reduce victim blaming.

Using interventions to reduce seclusion and mechanical restraint use in adult psychiatric units: an integrative review

The aim of this integrative review was to describe interventions aimed at reducing seclusion and mechanical restraint use in adult psychiatric inpatient units and their possible outcomes. CINAHL, MEDLINE, PsycINFO and Medic databases were searched for studies published between 2008 and 2017. Based on electronic and manual searches, 28 studies were included, and quality appraisal was carried out. Data were analysed using inductive content analysis. Interventions to proactively address seclusion were environmental interventions, staff training, treatment planning, use of information and risk assessment. Interventions to respond to seclusion risk were patient involvement, family involvement, meaningful activities, sensory modulation and interventions to manage patient agitation. Interventions to proactively address mechanical restraint were mechanical restraint regulations, a therapeutic atmosphere, staff training, treatment planning and review of mechanical restraint risks. Interventions to respond to mechanical restraint risks included patient involvement, therapeutic activities, sensory modulation and interventions to manage agitation. Outcomes related to both seclusion and mechanical restraint reduction interventions were varied, with several interventions resulting in both reduced and unchanged or increased use. Outcomes were also reported for combinations of several interventions in the form of reduction programmes for both seclusion and mechanical restraint. Much of the research focused on implementing several interventions simultaneously, making it difficult to distinguish outcomes. Further research is suggested on the effectiveness of interventions and the contexts they are implemented in.

Mental Health Nursing Practice and Indigenous Australians: A Multi-Sited Ethnography

Criticism of public mental services provided to Indigenous Australians have persisted over the last two decades, despite several national reports and policies that have attempted to promote positive service change. Mental health nurses represent the largest professional group practising within these services. This paper reports on a multi-sited ethnography of mental health nursing practice as it relates to this group of mental health service users. It explores the beliefs and ideas that nurses identified about specialist mental health nursing practice and Indigenous Australians. The study found a disunited approach to practice during the fieldwork. Practice was expressed as a series of individual constructions built upon the nurses' beliefs about Indigenous Australians and their experiences in practice with these peoples. The criticism of mental health services from Indigenous communities was understandable to the mental health nurses, but how they could address this through their individual practices was not always clear to them. The actions by public mental health services to improve cultural safety through generic training related to the broad area of Indigenous health and health service needs, does not appear to evolve into informed specialist mental health nursing practice for Indigenous Australian service users.

Secondary analysis of data can inform care delivery for Indigenous women in an acute mental health inpatient unit

There is a paucity of research exploring Indigenous women's experiences in acute mental health inpatient services in Australia. Even less is known of Indigenous women's experience of seclusion events, as published data are rarely disaggregated by both indigeneity and gender. This research used secondary analysis of pre-existing datasets to identify any quantifiable difference in recorded experience between Indigenous and non-Indigenous women, and between Indigenous women and Indigenous men in an acute mental health inpatient unit. Standard separation data of age, length of stay, legal status, and discharge diagnosis were analysed, as were seclusion register data of age, seclusion grounds, and number of seclusion events. Descriptive statistics were used to summarize the data, and where warranted, inferential statistical methods used SPSS software to apply analysis of variance/multivariate analysis of variance testing. The results showed evidence that secondary analysis of existing datasets can provide a rich source of information to describe the experience of target groups, and to guide service planning and delivery of individualized, culturally-secure mental health care at a local level. The results are discussed, service and policy development implications are explored, and suggestions for further research are offered.

Consumers and Carer perspectives on poor practice and the use of seclusion and restraint in mental health settings: results from Australian focus groups

BACKGROUND

Seclusion and restraint are interventions currently permitted for use in mental health services to control or manage a person's behaviour. In Australia, serious concerns about the use of such seclusion and restraint have been raised at least since 1993. Consumers and their supporters have also expressed strong views about the harm of these practices. This paper presents the results of ten focus group discussions with people with lived experience of mental health issues and also carers, family members and support persons in relation to the use of seclusion and restraint.

METHODS

The 30 consumers and 36 supporters participating in the focus groups convened in four Australian cities and one regional centre discussed their understandings of the use of seclusion and restraint and its impact on the people involved. Participants also presented their observations about poor practice and what contributes to it as well as providing ideas and recommendations regarding strategies to reduce or eliminate seclusion and restraint. Focus group discussions were recorded and transcribed, then analysed using the NVivo 10 qualitative data analysis software with a general inductive approach used to analyse data. This analysis enabled consideration of the responses to key questions in the focus groups as well as the identification of emerging themes.

RESULTS

Six themes emerged from the analysis, these being: human rights, trauma, control, isolation, dehumanisation and 'othering', and anti-recovery. Examples of poor practice identified by focus groups included the use of excessive force, lack of empathy/paternalistic attitudes, lack of communication and interaction and a lack of alternative strategies to the use of seclusion and restraint. There was a confluence of factors identified by participants as contributing to poor practice, with the main factors being organisational culture, the physical environment, under-resourced mental health services and fear and stigma.

CONCLUSIONS

Focus group participants in the main viewed seclusion and restraint practices in mental health settings as unnecessarily overused, exacerbating problems for individuals, carers, staff and the broader system of care. This study highlights that lived experience of both consumers and their supporters can make an important contribution to mental health services and its ongoing reform.

Acute mental health service delivery to Indigenous women: What is known?

The Australian College of Mental Health Nurses directs that mental health nurses must 'enable cultural safety in practice, taking into account age, gender, spirituality, ethnicity and health values'. The present study is a review of the existing literature undertaken in order to identify current knowledge and knowledge gaps regarding the experience of Indigenous women in acute mental health inpatient facilities. In particular, studies that identified environments and practices promoting the development of culturally-safe healing spaces for Indigenous women, and studies that identified women's experience of seclusion, were sought. The results showed that there is little literature directly relevant to Indigenous women's experiences of inpatient mental health units in Australia. The present study consolidates existing knowledge and knowledge gaps, and advances the argument for gender-disaggregated future research. Implications for professional practice and service development are also noted.