Fear and blame in mental health nurses' accounts of restrictive practices: Implications for the elimination of seclusion and restraint

Exploring the relationship between compassion fatigue, stigma, and moral distress among psychiatric nurses: a structural equation modeling study

BACKGROUND

Psychiatric nurses experience unique emotional and ethical challenges, including moral distress, associative stigma, and compassion fatigue, that can negatively affect their mental health and clinical performance. The complex relationship among these variables has not been clearly defined. Thus, this study aimed to determine the levels of compassion fatigue, associative stigma, and moral distress and to investigate how these factors interact with an emphasis on the role of compassion fatigue in mediating the relationship between associative stigma and moral distress.

METHODS

A convenient sampling technique was used to recruit nurses from Erada Mental Health Complex in Riyadh. In addition to sociodemographic data, three validated tools were used to collect data: the Compassion Fatigue Scale, Clinician Associative Stigma Scale, and Moral Distress for Healthcare Professionals Scale. The structural equation modeling was used to examine the relationship among the three variables using the 'lavaan' package.

RESULTS

Mediation analysis revealed that compassion fatigue significantly mediates the relationship between associative stigma and moral distress, with 80% of the total effect mediated (β = 6.38, p < 0.001). Direct and indirect effects were confirmed, with associative stigma impacting moral distress both directly (β = 1.64, p < 0.001) and through compassion fatigue (84% of the effect). Structural equation modeling showed a satisfactory model fit (χ²/df = 2.84, CFI = 0.90, RMSEA = 0.075) and supported the central role of compassion fatigue in this relationship.

CONCLUSIONS

Our findings underscore the importance of addressing compassion fatigue and associative stigma to alleviate moral distress among psychiatric nurses. To ensure nurses' well-being and the delivery of high-quality mental health care, interventions such as peer support groups, resilience training, and organizational initiatives to decrease stigma and compassion fatigue should be considered for all nurses working in psychiatric mental health settings.

CLINICAL TRIAL NUMBER

Not applicable.

An Initial Investigation into Mental Health Clinicians' Aims to Reduce Restrictive Practices

PURPOSE

Internationally, service users and their families have raised concerns about safety in current mental health service delivery. Underfunding and risk-averse management practices are implicated as key challenges. This study aimed to explore initial clinician perspectives on needed changes to reduce restrictive interventions and to improve conditions for service users and staff alike.

MATERIALS AND METHODS

Utilizing a co-operative inquiry approach, this unique study was clinician-led and co-produced by researchers and clinicians. Community and Emergency Department Crisis Mental Health Clinicians (from both nursing and social work backgrounds) explored their use of restrictive interventions, and what they need from policy and resources to change practices. Clinician-researchers collected data across two meetings, subsequently co-conducted a thematic analysis of their reflections in a group setting, and co-produced the write up and reflections of the results.

RESULTS

Seven themes were developed which explored: the holding of risk; over interventions, imperfect solutions; containment seeking; time's importance in the holding of risk; least restrictive environments; and holding risk as an isolating practice. These themes are presented as questions that arose through these discussions, as clinician-researchers reflected on their own practice.

DISCUSSION

The environments where crisis clinicians work are not designed for least restrictive practice, despite these clinicians often find creative and thoughtful solutions to imperfect circumstances.

CONCLUSION

This study models and encourages deep dialogue toward redesigned policy and practices and for future research.

Clinical Risk Management in Mental Health Services: 10 Principles for Best Practice

Risk assessment and management are a fundamental part of clinical practice globally within mental health services. In the United Kingdom (UK), the evidence to support the effectiveness of structured risk assessment and management remains limited, although the perception remains that structured management frameworks are effective in reducing risk in mental health care. Despite the importance of risk management within mental health services, the most recent UK wide guidance was published in 2009, while international guidance for the assessing and management of service user risks also appears sparse. This perspective paper reports on a consultation and co-production project to provide up-to-date best practice principles in clinical risk management to enhance the consistency, quality and safety of mental health practice in the UK mental health services, and for mental health services in other English speaking countries. A three-stage approach was used including literature review, referral to mental health experts for review and final evaluation and sign off by users of mental health services as experts by experience. Ten principles for best practice were confirmed as a benchmark for practice and are offered as a benchmark to improve the quality and safety of mental health practice.

Barriers and Facilitators-Lessons Learned From a Randomised Trial to Implement Clinical Practice Guidelines for the Prevention of Coercion in Psychiatry

The PreVCo study ('Prevention of Violence and Coercion') investigated the effects of a structured programme for the implementation of guideline recommendations for the management of aggression and the prevention of violence and coercion in psychiatric hospitals in a multicentre randomised controlled trial with 55 participating wards. The intervention was a 1-year individually tailored implementation programme supported by external consultants. An independent evaluation of the individual wards' process aimed at identifying barriers and facilitators in implementation. We conducted guideline-based group interviews with 53 of 55 participating teams during the implementation process. The Consolidated Framework for Implementation Research (CFIR) was used for the qualitative analysis. Two coders independently coded the transcripts and conducted a summary content analysis. The focus was on facilitators and barriers in the implementation process. The design of the intervention, in particular the framework of a controlled study, external guidance and the opportunity to choose and adapt the implementation programme according to the wards' possibilities and needs, was generally perceived as useful and supportive. The context of pandemic management at the time of the study interfered with the implementation process, mostly because of organisational transformations, challenges for information exchange and increased workload of the staff. With regard to the wards participating in the study, the main facilitators were a receptive, collaborative ward culture, team spirit and previous experiences in successful transformation processes. Barriers included the demanding working situation, frequent fluctuation of staff and low team cohesion, obstacles in communication, a deficit-oriented perception of patients and low priority of the implementation process. Provision of necessary resources by the organisation was not self-evident. Stakeholders devoted to the ideas of transformation of psychiatry and reduction of coercion were important facilitators of the implementation; however, some employees kept a resigned attitude and could not be engaged. The analysis of barriers and facilitators shows that an implementation process of innovative routines on psychiatric wards can benefit from external, individually tailored guidance. However, the working conditions on psychiatric wards remain to be challenging. Trial Registration: Clinical Trial Registration at www.isrctn.com with the identifier ISRCTN 71467851.

On Being Open in Closed Places: Vulnerability and Violence in Inpatient Psychiatric Settings

High levels of violence and conflict occur in inpatient psychiatric settings, causing a range of psychological and physical harms to both patients and staff. Drawing on critiques of vulnerability from the philosophical literature, this paper contends that staff's understanding of their relationship with patients (including how they should respond to violence and conflict) rests on the dominant, reductive account of vulnerability. This account frames vulnerability as an increased susceptibility to harm and so regards 'invulnerable' staff's responsibility to be protecting and managing vulnerable patients. We offer an alternative view of vulnerability as an openness and capability to be changed, which illuminates how the common account of vulnerability is used to justify staff's coercive power over patients and to control staff behaviour. Our main argument is that staff's adoption of this negative approach to vulnerability is associated with a range of factors that are connected to the violence and conflict endemic to these settings. Staff's need to situate themselves as invulnerable and therefore incapable of harm, we argue, leads to significant issues through: damaging staff ability to emotionally regulate; coercing patients into an asymmetrical openness leading to aggression to restore status; damaging therapeutic relationships by enforcing separation between staff and patients; increasing staff's reliance on unhelpful and rigid techniques (such as de-escalation); repressing staffs' ability to learn and grow through encounters with patients. Finally, we offer recommendations for how vulnerability and openness could be cultivated as a relational and radical practice in spaces that are traditionally closed and hostile to it.

Staff support for workplace trauma: a freedom of information act request survey for NHS trusts providing mental health care in England

INTRODUCTION

Workplace trauma in mental health settings is defined as exposure to verbal and physical aggression, witnessing self-harm or hearing about patients' histories of abuse. Support for workplace trauma is important for staff well-being, staff retention and ultimately patient care. Assessing the extent and adequacy of staff support for workplace trauma in mental health settings is important in identifying areas of need and good practice.

AIM

To determine what staff support systems are in place for workplace trauma in mental health services across England.

METHODS

Freedom of Information Act requests were sent to all 57 National Health Service Trusts providing mental health care in England to identify policies on the support to mental health staff after traumatic incidents that they have experienced in the course of their clinical duties.

RESULTS

Fifty-five Trusts provided usable data. Only half provided evidence of a psychologically informed incident response that went beyond a fact-finding exercise and only a fifth of Trusts used an established model for the response process. A small proportion of policies acknowledged workplace traumas related to staff discrimination on the basis of protected characteristics.

CONCLUSION

There is insufficient attention to supporting mental health staff with the effects of workplace trauma.

A Scoping Review of Australian New Graduate Nurse Preparation to Work in Mental Health Settings

Objectives: The review explores current evidence on Australian pre-registration nurse education in preparing graduates to work in mental health settings, from the perspectives of the graduates. Design: A scoping review using the Joanna Briggs Institute framework for scoping reviews and the Preferred Reporting Items for Systematic and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist was undertaken. Results: There were 31 eligible publications, reporting 12 qualitative studies, eight surveys and 11 quasi-experimental studies. All were in English language peer reviewed journals, published between 2000 and July 2023. Five themes emerged: 1. Well-organised and supported clinical placements can reduce stigma; 2. Student concerns regarding mental health clinical placements can be lessened when placements are well-designed; 3. Well-organised and resourced clinical placements can increase interest in mental health nursing; 4. Simulation learning can increase confidence during clinical placements; 5. Teaching by Experts By Experience (EBE) can reduce stigma and improved student attitudes. Conclusion: Evidence from 31 eligible publications indicated that properly resourced, purpose-designed theoretical and clinical learning experiences can be effective in reducing stigmatising attitudes and behaviours in pre-registration nursing students. Involving EBEs in mental health teaching is an important, but so far under-utilised, development in pre-registration nursing programmes in Australia.

Re-Examining the Predictive Validity and Establishing Risk Levels for the Dynamic Appraisal of Situational Aggression: Youth Version

The Dynamic Appraisal of Situational Aggression: Youth Version (DASA:YV) is a brief instrument, most often used by nurses and was specifically designed to assess risk of imminent violence in youth settings. To date, it has been recommended that DASA:YV scores are interpreted in a linear manner, with high scores indicating a greater level of risk and therefore need more assertive and immediate intervention. This study re-analyses an existing data set using contemporary robust data analytic procedures to examine the predictive validity of the DASA:YV, and to determine appropriate risk bands. Mixed effect logistic regression models were used to determine whether the DASA:YV predicted aggression when the observations are correlated. Two approaches were employed to identify and test novel DASA:YV risk bands, where (1) three risk bands as previously generated for the adult DASA were used as a starting point to consider recategorising the DASA:YV into three risk bands, and (2) using a decision tree analysis method known as Chi-square automated interaction detection to produce risk bands. There was no statistically significant difference between a four and three category of risk band. AUC values were 0.85 for the four- and three-category options. A three-category approach is recommended for the DASA:YV. The new risk bands may assist nursing staff by providing more accurate categorisation of risk state. Identification of escalation in risk state may prompt early intervention, which may also prevent reliance on the use of restrictive practices when young people are at risk of acting aggressively.

Moral distress among acute mental health nurses: A systematic review

Moral distress has been identified as an occupational hazard for clinicians caring for vulnerable populations. The aim of this systematic review was (i) to summarize the literature reporting on prevalence of, and factors related to, moral distress among nurses within acute mental health settings, and (ii) to examine the efficacy of interventions designed to address moral distress among nurses within this clinical setting. A comprehensive literature search was conducted in October 2022 utilizing Nursing & Allied Health, Embase, CINAHL, PsychInfo, and PubMed databases to identify eligible studies published in English from January 2000 to October 2022. Ten studies met inclusion criteria. Four quantitative studies assessed moral distress among nurses in acute mental health settings and examined relationships between moral distress and other psychological and work-related variables. Six qualitative studies explored the phenomenon of moral distress as experienced by nurses working in acute mental health settings. The quantitative studies assessed moral distress using the Moral Distress Scale for Psychiatric Nurses (MDS-P) or the Work-Related Moral Stress Questionnaire. These studies identified relationships between moral distress and emotional exhaustion, depersonalization, cynicism, poorer job satisfaction, less sense of coherence, poorer moral climate, and less experience of moral support. Qualitative studies revealed factors associated with moral distress, including lack of action, poor conduct by colleagues, time pressures, professional, policy and legal implications, aggression, and patient safety. No interventions targeting moral distress among nurses in acute mental health settings were identified. Overall, this review identified that moral distress is prevalent among nurses working in acute mental health settings and is associated with poorer outcomes for nurses, patients, and organizations. Research is urgently needed to develop and test evidence-based interventions to address moral distress among mental health nurses and to evaluate individual and system-level intervention effects on nurses, clinical care, and patient outcomes.

Tree: Reducing the use of restrictive practices on psychiatric wards through virtual reality immersive technology training

BACKGROUND

Restrictive practices (RPs) are defined by measures linked to physical and chemical restraints to reduce the movement or control behaviours during any emergency. Seclusion is an equal part of RPs intended to isolate and reduce the sensory stimulation to safeguard the patient and those within the vicinity. Using interventions by way of virtual reality (VR) could assist with reducing the need for RPs as it could help reduce anxiety or agitation by way of placing users into realistic and immersive environments. This could also aid staff to and change current RPs.

AIM

To assess the feasibility and effectiveness of using a VR platform to provide reduction in RP training.

METHODS

A randomised controlled feasibility study, accompanied by evaluations at 1 month and 6 months, was conducted within inpatient psychiatric wards at Southern Health National Health Service Foundation Trust, United Kingdom. Virti VR scenarios were used on VR headsets to provide training on reducing RPs in 3 inpatient psychiatric wards. Outcome measures included general self-efficacy scale, generalised anxiety disorder assessment 7 (GAD-7), Burnout Assessment Tool 12, the Everyday Discrimination Scale, and the Compassionate Engagement and Action Scale.

RESULTS

Findings revealed statistically significant differences between the VR and treatment as usual groups, in the Everyday Discrimination Scale items Q8 and Q9: P = 0.023 and P = 0.040 respectively, indicating higher levels of perceived discrimination in the VR group. There were no significant differences between groups in terms of general self-efficacy, generalised anxiety disorder assessment 9, and Burnout Assessment Tool 12 scores. A significant difference was observed within the VR group for compassionate engagement from others (P = 0.005) over time. Most respondents recorded System Usability Scale scores above 70, with an average score of 71.79. There was a significant reduction in rates of RPs in the VR group vs treatment as usual group with a fluctuating variability observed in the VR group likely due to external factors not captured in the study.

CONCLUSION

Ongoing advancement of VR technology enables the possibility of creating scenarios and simulations tailored to healthcare environments that empower staff by providing more comprehensive and effective training for handling situations.

The Maintenance Model of Restrictive Practices: A Trauma-Informed, Integrated Model to Explain Repeated Use of Restrictive Practices in Mental Health Care Settings

Nurses are at the forefront of care in mental health services but their role is conflicted; they carry the most responsibility for care and also for restrictive practices. The harmful effects of restrictive practices for mental health patients are well documented, have attracted negative media attention, public concern, and criticism directed specifically at nursing staff. The need to reduce restrictive practices has been highlighted by patients, carer groups, legislators, policy makers, academics, and mental health service providers. Policies and best practice guidelines have resulted, but restrictive practices remain a global problem. This theory paper proposes that inertia is partly due to the absence of a coherent model that explains the initiation and maintenance of restrictive practice in inpatient mental health settings. The conceptual development and synthesis of the model and its practical implications are discussed.

American Psychiatric Nurses Association Position: Staffing Inpatient Psychiatric Units

OBJECTIVE

An American Psychiatric Nurses Association (APNA) task force reviewed current staffing research to revise and update the 2011 APNA "Staffing inpatient psychiatric units" position paper and provide recommendations to the APNA Board of Directors on how psychiatric mental health (PMH) nurses might champion the staffing needs of inpatient psychiatric units.

METHODS

Current research on staffing and nursing practice in inpatient psychiatric units was reviewed as well as variables believed to influence staffing and nursing practice, such as consumer needs and workplace culture. Since current nurse staffing principles emphasize nursing value and how that value is connected to outcomes, the literature search included a focus on staffing and related patient outcomes.

RESULTS

PMH nurses are critical to the safety and quality of care in inpatient psychiatric units. However, there are little existing data on the relationship between staffing levels and even common adverse events such as staff injury and restraint of patients. Furthermore, there is scant research conducted on inpatient psychiatric units that informs optimal staffing models or establishes links between staffing and patient outcomes.

CONCLUSIONS

Consistent with current evidence, the universal use of a single method or model of determining staffing needs (e.g., nursing hours per, case mix index, or mandatory ratios) is not recommended. PMH nurses should champion systematic evaluation of staffing on their inpatient units against select patient, nurse, and system outcomes. A data repository of PMH nurse-sensitive outcomes is necessary to benchmark unit performance and staffing.

Exploring safety culture within inpatient mental health units: The results from participant observation across three mental health services

In Australia, acute inpatient units within public mental health services have become the last resort for mental health care. This research explored barriers and facilitators to safe, person-centred, recovery-oriented mental health care in these settings. It utilised participant observations conducted by mental health nurses in acute inpatient units. These units were located in three distinct facilities, each serving different areas: a large metropolitan suburban area in a State capital, a mid-sized regional city, and a small city with a large rural catchment area. Our findings highlighted that, in the three inpatient settings, nurses tended to avoid common areas they shared with consumers, except for brief, task-related visits. The prioritisation of administrative tasks seemed to arise in a situation where nurses lacked awareness of alternative practices and activities. Consumers spent prolonged periods of the day sitting in communal areas, where the main distraction was watching television. Boredom was a common issue across these environments. The nursing team structure in the inpatient units provided a mechanism for promoting a sense of psychological safety for staff and were a key element in how safety culture was sustained.

Art therapy is associated with a reduction in restrictive practices on an inpatient child and adolescent mental health unit

BACKGROUND

The elimination of restrictive practices, such as seclusion and restraint, is a major aim of mental health services globally. The role of art therapy, a predominantly non-verbal mode of creative expression, is under-explored in this context. This research aimed to determine whether art therapy service provision was associated with a reduction in restrictive practices on an acute inpatient child and adolescent mental health services (CAMHS) unit.

METHODS

The rate (events per 1,000 occupied bed days), frequency (percent of admitted care episodes with incident), duration, and number of incidents of restrictive practices occurring between July 2015 and December 2021 were analysed relative to art therapy service provision. The rate, frequency and number of incidents of intramuscular injected (IM) sedation, oral PRN (as-needed medication) use, and absconding incidents occurring in conjunction with an episode of seclusion or restraint were also analysed.

RESULTS

The rate, frequency, duration, and total number of incidents of seclusion, the frequency and total number of incidents of physical restraint, and the rate, frequency and total number of incidents of IM sedation showed a statistically significant reduction during phases of art therapy service provision.

CONCLUSIONS

Art therapy service provision is associated with a reduction in restrictive practices in inpatient CAMHS.

Managing Aggressive Behaviour in Healthcare: Balancing of Patients and Staff Interests

The incidence of aggression within healthcare environments has exhibited a discernible rise. As a response, restrictive measures, including restraints, are enforced. Due to the safety and ethical concerns associated with using restraint, de-escalation measures are regarded as the most efficient course of action. The paper posits that it is critical to identify the causes of aggression before employing restraint through a multidisciplinary risk assessment. In addition, the reasonableness and proportionality of administering restraint must be carefully measured. The significance of cultivating a therapeutic and compassionate environment is emphasised. The paper will exclusively examine physical restraint as a form of restriction intervention.

A systematic review of interventions to reduce mechanical restraint in adult mental health inpatient settings

Mechanical restraint is a commonly used restrictive practice worldwide, although reducing its use is an international priority. Interventions to reduce mechanical restraint are needed if reducing mechanical restraint is to succeed. Therefore, this systematic review aimed to examine evaluated evidence-based interventions that seek to reduce the incidence of and/or time in mechanical restraint in adult mental health inpatient settings. The JBI framework was used to guide this systematic review. The search strategy included peer-reviewed primary research literature published between 1999 and 2023. Two authors independently conducted the systematic search, selection process and data extraction process. Forty-one studies were included in this review. Using content analysis, we grouped interventions into four categories: (I) calm-down methods, (II) staff resources, (III) legal and policy changes and (IV) changing staff culture. Interventions to reduce mechanical restraint in adult mental health inpatient settings have shown some promise. Evidence suggests that a range of interventions can reduce the incidence of and/or time in mechanical restraint. However, controlled trials were lacking and consensus was lacking across studies. Furthermore, specific findings varied widely, and reporting was inconsistent, hampering the development of interventions for this issue. Further research is needed to strengthen the evidence base for reducing mechanical restraint in mental health inpatient settings.

In their own words: Mental health nurses' experiences of trauma-informed care in acute mental health settings or hospitals

Trauma-informed care has emerged as a prominent strategy to eliminate coercive practices and improve experiences of care in mental health settings, with advocacy from international bodies for mental health reform. Despite this, there remains a significant gap in research understanding the integration of trauma-informed care in mental health nursing practice, particularly when applied to the acute mental health or hospital-based setting. The study aimed to explore the experiences of mental health nurses employed in acute hospital-based settings from a trauma-informed care perspective. The study design was qualitative, using a phenomenological approach to research. A total of 29 nurses employed in acute mental health or hospital-based environments participated. Three over-arching themes were uncovered: 'Embodied Awareness': highlighting mental health nursing emotional capabilities are deeply rooted in bodily awareness. 'Navigating Safety': signifying spatial elements of fear and how some mental health nurses' resort to coercive or restrictive practices for self-preservation. 'Caring Amidst Uncertainty': revealing the relational influences of security guards in mental health nursing. The study reveals a significant gap in trauma-informed care implementation when applied to the context of mental health nursing practice in this setting. Limited evidence on trauma-informed care for mental health nurses, coupled with inadequate workforce preparation and challenging work environments, hinder the effective integration of it. To genuinely embed TIC in acute mental health settings, the study emphasises the need for a thorough exploration of what this entails for mental health nurses.

Staff responses to interventions aiming to reduce mechanical restraint in adult mental health inpatient settings: a questionnaire-based survey

PURPOSE

To explore mental health staff's responses towards interventions designed to reduce the use of mechanical restraint (MR) in adult mental health inpatient settings.

METHODS

We conducted a cross-sectional, questionnaire-based survey. The questionnaire, made available online via REDCap, presented 20 interventions designed to reduce MR use. Participants were asked to rate and rank the interventions based on their viewpoints regarding the relevance and importance of each intervention.

RESULTS

A total of 128 mental health staff members from general and forensic mental health inpatient units across the Mental Health Services in the Region of Southern Denmark completed the questionnaire (response rate = 21.3%). A total of 90.8% of the ratings scored either 'agree' (45.2%) or 'strongly agree' (45.6%) concerning the relevance of the interventions in reducing MR use. Overall and in the divided analysis, interventions labelled as 'building relationship' and 'patient-related knowledge' claimed high scores in the staff's rankings of the interventions' importance concerning implementation. Conversely, interventions like 'carers' and 'standardised assessments' received low scores.

CONCLUSIONS

The staff generally considered that the interventions were relevant. Importance rankings were consistent across the divisions chosen, with a range of variance and dispersion being recorded among certain groups.

Exploring the impact of a multilevel intervention focused on reducing the practices of seclusion and restraint in acute mental health units in an Australian mental health service

Reducing and eliminating seclusion and restraint in inpatient settings has been a key area of focus in mental health policy and research for many years. To address this issue, numerous programmes aimed at minimising the use of these practices have been developed over the past two decades, with varying degrees of success. This article reports on research focused on the implementation of a localised, multilevel complex intervention that targeted both organisational and individual factors related to the use of seclusion and restraint. The researchers followed the impact of the intervention by interviewing medical, nursing and allied health staff who worked within the service (N = 12) and analysing the rates of seclusion and restraint over an 18-month period. Post-adoption, participants identified that there were clear changes in practice culture. Seclusion clearly became a practice of last resort and other options became prominent in staff's practice. Participants identified that there was a sense of shared purpose across the multidisciplinary team. The clinical environment was viewed as being more therapeutic for service users and less frightening for staff. There was a significant difference in the total number of seclusion events between pre- (Mean = 6.22, SD = 5.82) and post-implementation (Mean = 2.55, SD = 2.44, p = 0.002, d = 0.94), demonstrating a significantly lower number of seclusions was observed after the intervention. Similarly, a significant difference in restraint events between pre- (Mean = 5.50, SD = 3.77) and post-implementations (Mean = 3.38, SD = 3.21, p = 0.037, d = 0.62) was observed.

Implementation and Adaptation of the Safewards Model in the New Zealand Context. Perspectives of Tāngata Whai Ora and Staff

The safety of service users and staff is paramount in cultivating a therapeutic environment within inpatient mental health units. The Safewards model, originating in the United Kingdom, aims to reduce conflict and containment rates through 10 interventions. This study used participatory action research to explore the perspective of tāngata whai ora and staff regarding the adaptation of the Safewards model to the unique New Zealand context. Such adaptation is critical due to significant health outcome disparities between Māori and non-Māori populations and the disproportionate representation of Māori within mental health services. In adhering to the principles of Te Tiriti o Waitangi, cultural adaptation becomes an imperative obligation. The study utilised qualitative content analysis and thematic analysis, drawing data from focus groups of staff (n = 15) and tāngata whai ora (n = 3). This study describes a New Zealand Safewards model, which must include Te Ao Māori, align with current practices, adapt Safewards interventions and gain acceptance. Organisational change management is pivotal in the integration of this model into nursing practice. The outcomes of this study hold the potential to contribute to the formulation and implementation of a New Zealand Safewards model, while also bearing relevance for the international adaptation of Safewards to culturally diverse countries and healthcare systems.

Staff Perspectives in Mental Health Research Regarding Restrictive Interventions: An Australian Scoping Review and Thematic Analysis

Service users and their families have raised concerns about safety in current acute mental health service delivery. Restrictive interventions are routinely used across mental health settings despite increasing awareness of the negative impacts. Underfunding and risk-averse management practices are implicated as key challenges. Utilizing a scoping review and thematic analysis method, this review explored the existing literature of mental health staff perspectives across various settings (including psychiatric wards and emergency departments), focusing on their experience of restrictive interventions. Four themes were developed: 1. Safety (both staff and patient); 2. Barriers to staff reducing their restrictive interventions; 3. Strength in current practice; 4. Recommendations for change. Key gaps in the literature were the limited perspectives of emergency and crisis clinicians (despite these areas being settings where restrictive interventions are utilized) and limited perspectives from allied health disciplines (despite their employment as clinicians in these settings). It also noted a divide between staff and patient safety, as though these concerns are mutually exclusive rather than cooccurring, which is the experienced reality. Advocacy bodies, governments and the media are calling for a reduction in restrictive interventions in crisis settings. This research synthesis proposes that, to achieve this, clinical staff must be involved in the process and their perspectives actively sought and drawn upon to enable reform.

"It's not a nice thing to do, but…": A phenomenological study of manual physical restraint within inpatient adolescent mental health care

AIM

To explore nursing staff's experiences of using manual (physical) restraint within inpatient adolescent mental health care.

DESIGN

This was a descriptive phenomenological study.

METHODS

Individual semi-structured interviews were conducted with 12 nursing staff between March 2021 and July 2021. The nursing staff were recruited from four inpatient adolescent mental health hospitals across three National Health Service Trusts in England. Interviews were transcribed verbatim and analysed using Braun and Clarke's reflexive approach to thematic analysis.

RESULTS

Four themes were generated from the analysis: (1) it needs to be done sometimes; (2) it's not a nice thing to do; (3) it does not really damage the therapeutic relationship; and (4) importance of team support. Despite strongly reporting that it was sometimes necessary to manually restrain young people for substantial safety reasons, participants spoke with dislike about its use, and described consequential aversive experiences of emotional distress, patient aggression, pain and injury, and physical exhaustion. Participants reported relying on each other for emotional and practical support. Three participants reported observing premature restraint use by non-permanent staff.

CONCLUSION

The findings detail a paradoxical picture of the nursing staff's experiences where restraint is experienced as psychologically and physically aversive yet deemed as sometimes necessary to prevent significant harm.

REPORTING METHOD

The Standards for Reporting Qualitative Research (SRQR) checklist was used to guide reporting.

IMPACT

This study suggests a need for the targeting of non-permanent staff for restraint minimization interventions, and highlights how the treatment of non-permanent staff by permanent staff may contribute to avoidable restraint practices. The findings indicate several ways in which the staff-young person therapeutic relationship can be preserved in the context of restraint. However, this needs to be treated with caution given that young people's voices were missing from this study.

PATIENT OR PUBLIC CONTRIBUTION

This study focused on nursing staff's experiences.

Experiencing restraint: A dialogic narrative inquiry from a service user perspective

In recent decades concerns about violence and programs for the minimization of physical restraint, amongst other restrictive practices, have proliferated within mental health policy and practice. Whilst nurses are often called upon when violence occurs within mental health care settings, they often find themselves having the conflicting roles of caring and controlling. Within such situations it is service users, who are experts by experience, who perhaps can offer more meaningful insight into being restrained and thus provide a more appropriate approach in dealing with mental distress. This paper presents the findings of a narrative study of individuals' experiences of physical restraint within the mental health care system. In total 11 mental health service users, who had experienced physical restraint, were interviewed. Frank's (2010, Letting stories breathe: a socio-narratology) guiding questions were used to undertake a dialogical narrative analysis of each story. For the purpose of this paper, four of the 11 stories are presented as these are representative of Frank's 'quest narrative'. However, whilst studies from the service user perspective regarding restraint are scarce, findings are discussed in relation to the grand narrative of restraint. The dialogical relationship between individual stories and the dominant grand narrative implies that the former has the capacity to shape and review the latter within mental health care. Adding to the growing body of evidence of restraint from service users' perspectives could enable nurses to provide more appropriate and meaningful mental health care in times of mental distress. [238].

'You have to be a certain sort of person': An interpretative phenomenological analysis of mental health support workers' experiences of physical restraint in inpatient settings

Physical restraint is a controversial practice in psychiatric inpatient settings. Research has clearly demonstrated its physical and psychological risks, but few studies investigate how mental health support workers understand their experiences of restraint use. This study uses interpretative phenomenological analysis to explore support workers' understanding of these experiences. The COREQ checklist was used to ensure explicit reporting of the study. Semi-structured interviews were conducted with three participants and were then analysed using an interpretative phenomenological process. One superordinate theme emerged: 'You have to be a certain sort of person'. Restraints require not only the ability to overcome one's emotions, but also the ability to connect with the person being restrained. The implications of these findings for psychiatric care provision and for further research are discussed.

Barriers and enablers to managing challenging behaviours after traumatic brain injury in the acute hospital setting: a qualitative study

BACKGROUND

Challenging behaviours after traumatic brain injury (TBI) in the acute setting are associated with risk of harm to the patient and staff, delays in commencing rehabilitation and increased length of hospital stay. Few guidelines exist to inform practice in acute settings, and specialist services providing multi-disciplinary expertise for TBI behaviour management are predominantly based in subacute inpatient services. This study aims to investigate acute and subacute staff perspectives of barriers and enablers to effectively managing challenging behaviours after TBI in acute hospital settings.

METHODS

Qualitative focus groups were conducted with 28 staff (17 from acute setting, 11 from subacute setting) across two sites who had experience working with patients with TBI. Data were analysed using inductive-deductive reflexive thematic analysis. Data were applied to the constructs of the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to generate themes representing barriers and enablers to managing challenging behaviours after TBI in the acute hospital setting.

RESULTS

Four barriers and three enablers were identified. Barriers include (1) Difficulties with clinical decision making; (2) Concerns for risks to staff and patients; (3) Hospital environment; (4) Intensive resources are required. Enablers were (1) Experienced staff with practical skills; (2) Incorporating person-centred care; and (3) Supportive teams.

CONCLUSION

These findings can inform pre-implementation planning for future improvements to TBI behaviour management in acute hospital settings. Difficulties with clinical decision making, concerns for risks of injury, the hospital environment and lack of resources are major challenges. Implementation strategies developed to address barriers will need to be trialled, with multi-disciplinary team approaches, and tailored to the acute setting.

Developing entrustable professional activities to enhance application of an aggression prevention protocol

AIM

The research aim of this study was to seek feedback from prevention of aggression training experts about the suitability of Entrustable Professional Activities (EPAs) as an assessment tool for an Aggression Prevention Protocol. The protocol was designed to structure intervention to prevent aggression and reduce the use of restrictive practices following risk assessment using a validated instrument (the Dynamic Appraisal of Situational Aggression).

BACKGROUND

Preventing aggression and limiting the use of restrictive practices are key priorities for inpatient mental health services. Assessing clinical activities using a competence framework has limitations, particularly when determining complex interventions. EPAs could provide a suitable method for assessing complex clinical activities like de-escalation and limit setting, which comprise some of the interventions in the Aggression Prevention Protocol. EPAs are new to forensic mental health nursing; therefore, feedback was sought regarding the utility of EPAs to assess aggression prevention interventions.

METHODS

Data were collected via focus groups including 11 aggression prevention experts from Australia and New Zealand. A thematic analysis, comparative analysis and a Strength, Weakness, Opportunity and Threats analysis was conducted.

RESULTS

Three themes were interpreted from the data: 1) Frameworks such as the APP are needed to work towards elimination of restrictive practices; 2) APP-EPAs afford an opportunity to set the standard for practice; and 3) 'who watches the watchers', were identified by the experts as well as areas to enhance EPAs prior to introduction into practice.

CONCLUSIONS

EPAs address a practice-gap and offer a framework to assist movement towards elimination of restrictive practices, while prompting best-practice, self-reflection and practice improvement guidance.

Nurses' clinical decision-making in the use of rapid tranquillization in adult mental health inpatient settings: An integrative review

Rapid tranquillization is a restrictive practice that remains widely used in mental health inpatient settings worldwide. Nurses are the professionals most likely to administer rapid tranquillization in mental health settings. To improve mental health practices, an enhanced understanding of their clinical decision-making when using rapid tranquillization is, therefore, important. The aim was to synthesize and analyse the research literature on nurses' clinical decision-making in the use of rapid tranquillization in adult mental health inpatient settings. An integrative review was conducted using the methodological framework described by Whittemore and Knafl. A systematic search was conducted independently by two authors in APA PsycINFO, CINAHL Complete, Embase, PubMed and Scopus. Additional searches for grey literature were conducted in Google, OpenGrey and selected websites, and in the reference lists of included studies. Papers were critically appraised using the Mixed Methods Appraisal Tool, and the analysis was guided by manifest content analysis. Eleven studies were included in this review, of which nine were qualitative and two were quantitative. Based on the analysis, four categories were generated: (I) becoming aware of situational changes and considering alternatives, (II) negotiating voluntary medication, (III) administering rapid tranquillization and (IV) being on the other side. Evidence suggests that nurses' clinical decision-making in the use of rapid tranquillization involved a complex timeline with various impact points and embedded factors that continuously influenced and/or were associated with nurses' clinical decision-making. However, the topic has received scant scholarly attention, and further research may help to characterize the complexities involved and improve mental health practice.

Healthcare staff's experiences of using manual physical restraint: A meta-synthesis review

Manual restraint is a hands-on type of physical restraint used to prevent harm to service users and staff, and to administer necessary treatments. This article reports on a review and meta-synthesis of the qualitative literature on healthcare staff's experiences of using manual restraint. Three electronic databases (CINAHL Complete, MEDLINE, and PsycINFO) were systematically searched, and 19 studies were included. Thematic synthesis was used to synthesize the findings. The Critical Appraisal Skills Programme (CASP) checklist was used to appraise study quality. The synthesis generated one overarching interpretive theme, "unpleasant but necessary," and five subthemes: "maintaining safety triumphs all," "emotional distress," "significance of coping," "feeling conflicted," and "depletion." Seven studies indicated that, from staff perspectives, manual restraint was not always used as a last resort. Healthcare staff experience manual restraint as a psychologically and physically unpleasant practice, yet paradoxically deem its use to be sometimes necessary to keep themselves and service users safe from harm. The findings indicate a need for healthcare staff support, post-restraint debriefing meetings with service users, and the implementation of manual restraint minimization programs in healthcare settings.

The relationship between psychological resilience and professional quality of life among mental health nurses: a cross-sectional study

BACKGROUND

Mental health nursing is a demanding and stressful profession that impacts nurses' professional quality of life. Psychological resilience can be a protective factor. However, the relationship has not been extensively studied. This study aims to examine the relationship between psychological resilience and professional quality of life and identify potential predictors of ProQOL subscales among mental health nurses.

METHODS

The study employed a cross-sectional design to collect data from 179 mental health nurses. Data was collected using two standardized questionnaires: the Connor-Davidson resilience scale and the professional quality of life scale. Participants were recruited through convenient sampling during a 3-month period from April to June 2022, and the data were collected using an online survey tool called QuestionPro.

RESULTS

The study found a strong positive correlation between psychological resilience and compassion satisfaction (r = 0.632, P < 0.001). However, there was a negative significant correlation between resilience with burnout (r = -0.470, P < 0.001) and secondary traumatic stress (r = -0.210, P = 0.005). The study also found that higher resilience levels were associated with higher levels of compassion satisfaction and lower levels of secondary traumatic stress. Additionally, higher burnout scores were associated with higher levels of secondary traumatic stress. The study also identified that age and the number of children had weak associations with compassion satisfaction, while workplace was a significant predictor of burnout and secondary traumatic stress.

CONCLUSION

The study emphasizes the importance of resilience, burnout, and secondary traumatic stress in the well-being of healthcare professionals, especially nurses. The findings suggest that assessing nurses' resilience and professional quality of life can raise psychological resilience awareness and help managers create the necessary working conditions to improve nurses' professional quality of life.

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.

Promoting mental health recovery by design: Physical, procedural, and relational security in the context of the mental health built environment

The rates of mental health hospitalisations in Australia are rising. This paper presents the findings of a study undertaken in a regional mental health unit. The aim of the study was to obtain user perspectives to inform the redesign of the unit, which provides inpatient mental health services to rural and regional adults. A qualitative descriptive study with data collected via focus groups and in-depth interviews was undertaken with 38 participants, including current inpatients, carers and 27 staff members of a single regional inpatient mental health unit. The 25-bed mental health inpatient unit accommodates adults from 18+ years of age. The mental health unit sits within a referral hospital precinct and is associated with community-based mental health services within a large regional and rural Australian public health service. The analysis of interviews and focus groups with patients, carers and mental health professionals revealed three major themes congruent with the literature These were: Firstly, Theme 1: Rooms should be designed to promote physical security. Next, Theme 2: Purposeful planning to support interactions between users and systems will promote relational security. And finally, Theme 3: Optimizing service integrity should promote procedural security. Based on the themes arising from the study, a list of recommendations was produced to inform the design of a new build for a regional mental health unit. In particular, all users of the space should expect that the built environment will promote their physical security and psychological safety and accommodate a wide range of diversity and acuity. The aesthetics should align with the promotion of recovery in the context of person-centred and trauma-informed models of care. Designers should plan to alleviate boredom and accommodate meaningful wayfinding. Mental health nurses should have spaces that support their work without compromising their relational security with consumers. Building designers should optimize therapeutic environments to facilitate dignified intensive and stabilizing treatments and eliminate vicarious stigma associated with caring for people with mental illness. This study provides valuable insights from a community of users who have experienced receiving and delivering mental health care within a regional and rural mental health unit.

Safeguarding patients while implementing mechanical restraints: A qualitative study of nurses and ward staff's perceptions and assessment

AIMS AND OBJECTIVES

To explore nurses' and ward staff's perceptions and assessments of patient care while implementing mechanical restraints.

BACKGROUND

To prevent the risks associated with the use of restraints in psychiatry and ensure safe mental health care, it is necessary to know more about how the nursing staff experiences, comprehends and intervenes in managing patients subjected to coercive measures.

DESIGN

This study employed a qualitative descriptive design, in accordance with the COREQ guidelines.

METHODS

Semi-structured interviews were conducted with 18 nurses and ward staff aged between 22 and 45 years old, who had experience implementing mechanical restraints. Data were digitally audio-recorded and transcribed verbatim. Inductive thematic analysis was conducted using NVivo 12.

RESULTS

The participants believed that mechanical restraints should be used as a last resort and that safeguarding patients during implementation is important; however, their assessments of the patients' physical and mental conditions varied. A clear difference emerged in how management qualified professionals handled situations prior to and during the implementation of mechanical coercive measures.

CONCLUSIONS

The findings emphasise the need to focus on the assessment of patients prior to and during restraint, ensure the quality of safe implementation in a risk-of-harm situation, prioritise competence in education, and practice, and improve management.

RELEVANCE TO CLINICAL PRACTICE

The findings highlight the importance of assessing the physical and mental condition of patients while implementing restraints, as well as aiding the management, nurses and ward staff in tailoring safety procedures.

Social issues, crisis, and care coordination: First responders experience responding to people affected by methamphetamines

Methamphetamines remain a public health problem due to the extensive burden of illicit drug use on society. Callout events in the pre-hospital environment related to methamphetamine use is increasing. In addition, there has been an increase in reported mental health side effects and breakdown in relationships and social networks. Descriptive phenomenology research design was undertaken and data analysed using thematic analysis. Semi-structured interviews were utilized to collect data exploring the experience of first responders attending callouts to people affected by methamphetamines in the pre-hospital environment. Interviews included paramedics (8) and police officers (10) from across Australia. Overall, participants reported responding to people affected by methamphetamines was complex in nature. Complexity was affected by extensive social circumstances, people presenting in states of crisis, lack of coordinated approach, and unsuitable care environments. The social impact of methamphetamine addiction is extensive. Staff working as first responders have an opportunity to help reduce the social impact and crises, referring people to follow-up care and drug and alcohol support services. Further research is needed to determine if a standardized approach, between first responders and EDs, should be developed to help streamlines services and improve how the individual services respond as a group to people affected by substances.

NHS mental health services' policies on leave for detained patients in England and Wales: A national audit

WHAT IS KNOWN ON THE SUBJECT?: 'Leave' is a common occurrence for patients detained in mental health settings. The term covers multiple scenarios, for example short periods to get off the ward through to extended periods at home prior to discharge. Despite the frequency and importance of leave, there is very little research about how it is implemented and whether, and in what circumstances, it is effective. While there is legislation about leave in the Mental Health Act (1983) mental health services are free to implement their own policies or not to implement one at all. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The leave policies of NHS mental health services in England and Wales are highly inconsistent. The extent to which policies are consistent with guidance differs depending on which service is providing care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: It is very likely that, because of inconsistencies between services and policies, practice also differs. Clinicians need to understand their responsibilities in the leave process to ensure that patients are supported in their recovery journey. Policymakers need to revisit leave policies in light of evidence from this study.

ABSTRACT

INTRODUCTION: Considerable guidance is available about the implementation of leave for detained patients, but individual mental health services are free to determine their own policies.

AIM

To determine how consistent leave policies of NHS mental health services in England and Wales are with relevant guidance and legislation.

METHOD

A national audit of NHS mental health services leave policies. Data were obtained through web searching and Freedom of Information requests. Policies were assessed against 65 criteria across four domains (administrative, Responsible Clinician, types of leave and nursing). Definitions of leave-related terms were extracted and analysed.

RESULTS

Fifty-seven (91.9%) policies were obtained. There were considerable inconsistencies in how policies were informed by relevant guidance: Domain-level consistency was 72.3% (administrative), 64.0% (Responsible Clinician), 44.7% (types of leave) and 41.9% (nursing). Definitions varied widely and commonly differed from those in relevant guidance.

DISCUSSION

Mental health professionals are inconsistently supported by the policy in their leave-related practice. This could potentially contribute to inconsistent practice and leave-related patient outcomes.

IMPLICATIONS FOR PRACTICE

To ensure patients are treated fairly clinicians need to be aware of their responsibilities around leave. In some services, they will need to go beyond their organization's stated policy to ensure this occurs.

Developing a Trauma-Informed and Recovery-Oriented Alternative to 'Aggression Management' Training for a Metropolitan and Rural Mental Health Service

For clinicians working in mental health services, 'aggression management' training is generally prioritised, and often mandated. Traditional 'aggression management' training has the potential to reinforce the perception that violence and aggression are inevitable, and thus defensive and coercive practices are needed. This paper outlines the principles and processes that underpinned the development of two training programs designed as recovery-oriented and trauma-informed alternatives to traditional 'aggression management' training. The focus of the paper is on exploring how 'aggression management' training can be aligned with best practice principles. The programs were developed in a metropolitan and rural mental health service and aimed to reduce the need for defensive and coercive practices by promoting therapeutic engagement. A key feature of both programs is an orientation towards safety rather than risk. By embedding the principles of recovery and trauma-informed care in their development and orienting training towards enhancing safety, clinicians are provided with a new way of conceptualising and responding to 'aggression'. Experiential methods in the delivery of the training, and the co-design and co-delivery with peer (consumer) educators were important in supporting attitudinal change. To promote safety, the language and content of training programs must reflect contemporary principles and approaches such as trauma-informed care and recovery. This paper illustrates that to be effective, these principles and approaches must not just be described, but modelled in the development, design, and delivery of the training.

Nursing staff composition and its influence on seclusion in an adult forensic mental health inpatient setting: The truth about numbers

INTRODUCTION

Research on the influence of nursing staff composition and use of seclusion in the forensic mental health inpatient settings is sparse. Nursing staff composition refers to staffing levels, roles, gender ratio and skill mix of the ward teams. Internationally, the rates of seclusion in some forensic mental health inpatient settings have increased over the past 10 years despite global efforts to reduce and eliminate its use.

AIM

To examine whether the use of seclusion in a forensic mental health inpatient setting can be attributed to staffing composition or to contextual factors such as day of the week, month or other clinical factors.

METHOD

Retrospective data collection was conducted using seclusion data, daily ward reports and staff rosters. Data were collected for all shifts in the hospital over a six-month period.

RESULTS

Three staffing variables were identified as having an influence on the use of seclusion: the number of registered nurses on duty, the presence of the shift coordinator and having a lead nurse on shift.

DISCUSSION

Senior nurse oversight and guidance are important factors in assisting staff to identify clinical deterioration and intervene early which may assist services reduce the use of seclusion.

IMPLICATIONS FOR PRACTICE

As staffing levels and composition are modifiable, the results of this study may assist nurse leaders to consider workforce improvements to reduce seclusion use.

Spanish mental health nurses' experiences of mechanical restraint: A qualitative descriptive study

WHAT IS KNOWN ON THE SUBJECT?: Mechanical restraint is a common practice in mental healthcare settings in Spain, despite controversy. Mechanical restraint is perceived as a negative experience for nurses and service users. Mechanical restraint damages the nurse-patient therapeutic relationship, which is essential in providing quality care and promoting recovery. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The negative experiences of service users and mental health nurses arising from use of mechanical restraint affects both parties involved and results in trauma. Using mechanical restraint can provoke a moral injury in mental health nurses which can negatively impact on the establishment of trust within the therapeutic nurse-patient relationship. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses must be aware of the negative effects that mechanical restraint use has on both their practice and their day-to-day lives. Post-mechanical restraint debriefing is required to repair the damage to the trust aspect of the nurse-patient relationship. Involving service users in co-producing a debriefing framework may be a way to rebuild trust through constructive dialogue.

ABSTRACT

INTRODUCTION: Mechanical restraint is an intervention that causes harm to service users and nurses, yet continues to be used in many countries, including Spain. However, there is a lack of research exploring Spanish mental health nurses' experiences of using mechanical restraint.

AIM

To describe the experiences of mental health nurses who have used mechanical restraint in practice.

METHODS

A qualitative descriptive methodology was used and a purposive sample of 10 Spanish mental health nurses were interviewed about their experiences of using mechanical restraint. Thematic analysis was then employed to analyse interview data.

RESULTS

Participants' experiences of using mechanical restraint were mostly negative. Three main themes arose from the analysis of interview transcripts, (i) symmetrical trauma, (ii) moral injury and (iii) broken trust.

DISCUSSION

The use of restrictive practices, which can be perceived as counter-therapeutic, exposes nurses to risks such as moral injury and service users to broken trust in the therapeutic nurse patient relationship. Avoiding empathy in order to use mechanical restraint is counterproductive, in the understanding that empathy is key to reducing this intervention.

IMPLICATIONS FOR PRACTICE

Reducing or eliminating use of mechanical restraints should be a policy and practice priority due to the symmetrical harms it causes both nurses and service users. The trust aspect of the therapeutic nurse-patient relationship is a significant casualty when mechanical restraint is used, therefore involving service users in co-production of post-mechanical restraint debriefing can be an avenue for restoring this trust through dialogue.

Safewards: An integrative review of the literature within inpatient and forensic mental health units

Mental health inpatient units are complex and challenging environments for care and treatment. Two imperatives in these settings are to minimize restrictive practices such as seclusion and restraint and to provide recovery-oriented care. Safewards is a model and a set of ten interventions aiming to improve safety by understanding the relationship between conflict and containment as a means of reducing restrictive practices. To date, the research into Safewards has largely focused on its impact on measures of restrictive practices with limited exploration of consumer perspectives. There is a need to review the current knowledge and understanding around Safewards and its impact on consumer safety. This paper describes a mixed-methods integrative literature review of Safewards within inpatient and forensic mental health units. The aim of this review was to synthesize the current knowledge and understanding about Safewards in terms of its implementation, acceptability, effectiveness and how it meets the needs of consumers. A systematic database search using Medline, CINAHL, Embase and PsychInfo databases was followed by screening and data extraction of findings from 19 articles. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of empirical articles, and the Johanna Brigg's Institute (JBI's) Narrative, Opinion, Text-Assessment and Review Instrument (NOTARI) was used to undertake a critical appraisal of discussion articles. A constant comparative approach was taken to analysing the data and six key categories were identified: training, implementation strategy, staff acceptability, fidelity, effectiveness and consumer perspectives. The success of implementing Safewards was variously determined by a measured reduction of restrictive practices and conflict events, high fidelity and staff acceptability. The results highlighted that Safewards can be effective in reducing containment and conflict within inpatient mental health and forensic mental health units, although this outcome varied across the literature. This review also revealed the limitations of fidelity measures and the importance of involving staff in the implementation. A major gap in the literature to date is the lack of consumer perspectives on the Safewards model, with only two papers to date focusing on the consumers point of view. This is an important area that requires more research to align the Safewards model with the consumer experience and improved recovery orientation.

Delineating Quality Indicators of Inpatient Psychiatric Hospitalization

BACKGROUND

Assuring quality care is critical to the well-being and recovery of individuals receiving inpatient psychiatric treatment, yet a comprehensive map of quality inpatient care does not exist.

AIMS

To isolate and describe quality elements of inpatient psychiatric treatment.

METHODS

A survey queried psychiatric inpatient nursing leaders on what they considered to be critical elements of quality. The survey was emailed to 40 American Psychiatric Nurses Association members, and 39 individuals responded. In the survey, participants were asked to comment on the importance of six dimensions of quality as well as quality indicators used on their units.

RESULTS

Data from this survey indicate how thought leaders conceptualized quality of inpatient care. A unifying philosophy of care was endorsed as a quality element as was structure that affords staff available time on the unit-engaging with patients. While staffing levels were viewed as important, the respondents commented on the nuances between staffing and quality. Participants endorsed the importance of involving individuals in their treatment planning as well as tapping into patients' perspectives on the treatment experience.

CONCLUSIONS

The participants' responses compliment the quality literature and reinforce the need to develop a comprehensive map of quality elements. These elements interact in complex way, for instance, staffing, engagement, and teamwork is tied to the organizational structure and philosophy of care, which in turn facilitates consumer involvement in care. Thus, gauging the impact of quality on outcomes will demand consideration of the interaction of factors not just the linear relationship of one element to an outcome.

Living with restraint: Reactions of nurses and lived experience workers to restrictions placed on the use of prone restraint

Despite recent changes to mental health policy in Australia and overseas, physical restraint continues to be widely employed in mental health services. While mental health nurses have a critical role to play in supporting initiatives designed to reduce restraint, it is unclear how they feel about moves to restrict the use of prone restraint. In this qualitative study, focus group interviews were conducted with mental health nursing staff and lived experience workers (LEWs) to gain their perspectives on the use of physical restraint in general and the restrictions being placed on prone ('face down') restraint. Five themes emerged: justifying the need for restraint, reliance on the prone position, the position is not the issue, time limits, and the psychological impact. Although mental health nurses were concerned about the risks associated with physical restraint, they provided strong justification for continued use of the prone position. LEWs raised concerns about the psychological impact of prone restraint and noted the need for a greater emphasis on de-escalation and other restraint avoidance strategies. The findings highlight the complexities and challenges to be considered when developing initiatives to reduce reliance on the use of restraint in general, and prone in particular.

Experience of mental health nurses regarding mechanical restraint in patients with psychomotor agitation: A qualitative study

AIM

To explore mental health nurses' experiences whilst managing a patient with psychomotor agitation, and the factors that influence the decision to use mechanical restraints.

BACKGROUND

Psychomotor agitation is considered a potentially violent psychiatric emergency. The management of disruptive behaviours includes mechanical restraints as the last resort although its use has consequences for patients, professionals and the therapeutic relationship.

DESIGN

A qualitative study design with a hermeneutical approach was developed.

METHODS

A total of 31 nurses were purposively sampled from six short- and medium-stay mental health inpatient units. Data were obtained from semi-structured interviews. A thematic content analysis following the seven steps of Colaizzi's method was performed. Three researchers independently conducted an inductive analysis within a perspective of a hermeneutic paradigm. The COREQ checklist was followed in carrying out this research.

RESULTS

Four themes emerged from the analysis: 1) Nurses' perceptions of restraint methods, 2) Factors influencing decision-making, 3) Consequences for professionals of the use of mechanical restraint and 4) Alternatives to mechanical restraint.

CONCLUSIONS

Aspects such as the importance of teamwork, the issue of cognitive dissonance, ethical conflict and barriers to effecting the withdrawal of these measures affect the mental health nurse's decision-making process. The understanding of these aspects is crucial to further reducing its incidence and negative consequences and achieving the elimination of mechanical restraints.

RELEVANCE FOR CLINICAL PRACTICE

Knowing how nurses feel during the patient's episode of psychomotor agitation and which factors influence the decision on whether to apply coercive methods can guide us on the quality of care offered.

Virtual reality-based training for mental health staff: a novel approach to increase empathy, compassion, and subjective understanding of service user experience

Background

Mental health service users report that staff empathy is key to developing positive therapeutic relationships but promoting empathy in staff training is challenging. Staff may struggle to maintain their compassion, particularly in challenging settings, and have limited clinical confidence when treating conditions of which they lack subjective understanding. Novel interventions are required to address these needs.

Main body of the text

Virtual reality-based simulation training has been shown to be an effective training modality for healthcare professionals; it has the potential to deliver crucial empathy-building learning for frontline mental health staff due to its capacity to increase staff understanding of service users’ experiences. Virtual reality and simulation technology take interactivity and experiential learning to a level beyond which we have seen in teaching and training before. Subjective understanding is elicited because this is a technology for enhanced experiential learning, which in turn fosters greater empathy and compassion. Increased empathy in the workforce is likely to yield significant benefits for service users. Greater empathy in nursing is linked with reduced restrictive practices and reduced conflict between staff and service users. Restrictive practices, including restraint and seclusion, are widely used in mental health settings within the UK, and are an aspect of mental health nursing that is at odds with the therapeutic role of nursing. Despite these innovative developments, there are challenges ahead. Many nurses feel that complete eradication of restrictive practices is impossible and that barriers include a limitation of resources, communication, management, and lack of education. There is a need to make simulation training economically viable so that it can be upscaled and widely available. Therefore, greater investment and resources are needed to bring this innovative training to the wider workforce to support staff and to realise the benefits for service users.

Short conclusion

Virtual reality-based training has great potential for mental health staff, which could have important consequences in terms of improved staff empathy and reductions in harmful restrictive practices. Further research and funding for such training is necessary so that it can be more widely available.

Current trends in restrictive interventions in psychiatry: a European perspective

This article reviews current evidence on the use of coercive measures, including seclusion and restraint, in psychiatric in-patient settings in Europe. There is a particular focus on evidence regarding the use of mechanical restraint. The review seeks to describe when the use of restrictive interventions such as restraint may be necessary, to explore the use of restraint in certain specialist settings and to investigate current laws and European policies on seclusion and restraint. The current rates of restraint in European psychiatric settings are explored, with a discussion of the limitations of the evidence currently available. The article discusses various consequences of seclusion and restraint, potential alternatives to their use and strategies to minimise their use and harm to patients. The use of coercive measures from an international context is considered, to provide context.

Defensive practices in mental health nursing: Professionalism and poignant tensions

Mental health nursing is a skilled profession, well positioned to support patients towards recovery with evidence-based therapeutic interventions. However, the profession continues to be challenged by tensions surrounding the delivery of restrictive interventions and concerns over tendencies towards defensive practices. This paper examines the ambiguity this creates within the mental health nursing role. Organizational cultures that overvalue metrics and administrative tasks create barriers for therapeutic engagement while contributing to role confusion and stress within nursing. We need to address such structural constraints on nurses as mental health nurses' well-being is crucial to service delivery and the realization of therapeutic goals. From the UK perspective, authors argue that there is a need to examine service structures that foster compassionate and transformational leadership to enable mental health nurses to exercise the agency to practice therapeutically. Education and quality nursing research have a pivotal role to play in enabling this shift.

Mental health nurses' experience of challenging workplace situations: A qualitative descriptive study

Mental health nursing is acknowledged internationally as being a demanding profession; however, little is known about the range of experience and complexity of workplace challenges or their impacts on mental health nurses (MHN). This qualitative descriptive study aimed to examine and describe the range of challenging workplace situations experienced by MHN and is reported according to the Standards for Reporting Qualitative Research. An online cross-sectional survey collected demographic data and open-ended descriptions of workplace challenges experienced by n = 374 Australian MHN. Using a modified a priori framework, four categories of experience were derived through content analysis: consumer-related, colleague-related, nursing role-related, and organizational service-related challenges. Many accounts described a complex interplay of challenges. The findings extend prior knowledge on MHN experiences. Frequent workplace challenges included violence and aggression from consumers, bullying from colleagues, low staffing levels, and poor skill mix. Further extending the evidence, key challenges rarely described in prior literature were the psychological impacts of suicides and murder; the personal nature of threats from consumers; moral distress and concerns with colleagues' quality of practice; and exacerbation of practice-related issues by lack of support from colleagues and/or the organization. These have important implications for the profession and can inform targeted strategies to reduce stressors where possible, build staff well-being, support workforce retention, and improve the provision of quality care. The implementation of targeted policy and initiatives that focus on reducing key stressors and supporting practice are vital to staff retention and ensuring a high standard of practice in complex mental health workplaces.

Relationship between nurses' use of verbal de-escalation and mechanical restraint in acute inpatient mental health care: a retrospective study

Although the use of verbal de-escalation in nursing has been shown to be an effective tool for controlling agitation and avoiding mechanical restraint, there is scarce evidence supporting the use of de-escalation by nurses and factors related to the patients who ultimately receive mechanical restraint. This retrospective study sought to examine the relationship between the use of verbal de-escalation by nurses and the clinical profile of patients who had received mechanical restraint at an acute mental health unit. This study analysed the records of patients who had received mechanical restraint between the years 2012 and 2019. A bivariate analysis was initially performed, followed by multiple logistic regression analysis. A total of 493 episodes of restraint were recorded. Of these, in almost 40% of cases, no prior use of verbal de-escalation was noted. The factors associated with the use of verbal de-escalation by nurses were patients with a history of restraint episodes and patients who previously had been administered medication. Furthermore, episodes of mechanical restraint that occurred later during the admission were also associated with the use of de-escalation. These findings confirm the relevance of early nurse interventions. Consequently, it is important to establish an adequate therapeutic relationship from the start of hospitalization to facilitate getting to know the patient and to enable the timely use of verbal de-escalation, thus avoiding the use of mechanical restraint.

How may cultural and political ideals cause moral distress in acute psychiatry? A qualitative study

BACKGROUND

There is growing public criticism of the use of restraints or coercion. Demands for strengthened patient participation and prevention of coercive measures in mental health care has become a priority for care professionals, researchers, and policymakers in Norway, as in many other countries. We have studied in what ways this current ideal of reducing the use of restraints or coercion and attempting to practice in a least restrictive manner may raise morals issues and create experiences of moral distress in nurses working in acute psychiatric contexts.

METHODS

Qualitative interview study, individual and focus group interviews, with altogether 30 nurses working in acute psychiatric wards in two mental health hospitals in Norway. Interviews were recorded and transcribed. A thematic analytic approach was chosen.

RESULTS

While nurses sense a strong expectation to minimise the use of restraints/coercion, patients on acute psychiatric wards are being increasingly ill with a greater tendency to violence. This creates moral doubt and dilemmas regarding how much nurses should endure on their own and their patients' behalf and may expose patients and healthcare personnel to greater risk of violence. Nurses worry that new legislation and ideals may prevent acutely mentally ill and vulnerable patients from receiving the treatment they need as well as their ability to create a psychological safe climate on the ward. Furthermore, persuading the patient to stay on the ward can cause guilt and uneasiness. Inadequate resources function as external constraints that may frustrate nurses from realising the treatment ideals set before them.

CONCLUSIONS

Mental health nurses working in acute psychiatric care are involved in a complex interplay between political and professional ideals to reduce the use of coercion while being responsible for the safety of both patients and staff as well as creating a therapeutic atmosphere. External constraints like inadequate resources may furthermore hinder the healthcare workers/nurses from realising the treatment ideals set before them. Caught in the middle nurses may experience moral distress that may lead to physical discomfort, uneasiness and feelings of guilt, shame, and defeat. Pressure on nurses and care providers to reduce or eliminate the use of coercion and reduction of health care spending are incompatible demands.

An Educational Intervention to Decrease the Number of Emergency Incidents of Restraint and Seclusion on a Behavioral Health Unit

BACKGROUND

The objective of this study was to implement an educational intervention on an inpatient, behavioral health care unit with the goal of reducing the number of crisis interventions of seclusion or restraint.

METHOD

A quasi-experimental pretest and posttest design using De-escalate Anyone, Anywhere, Anytime training was employed with a focus of an increased understanding of a range of de-escalation techniques to use instead of restraint and seclusion.

RESULTS

A convenience sample of 21 mental health employees participated in the training. The rates of restraint declined from a mean of 6 preintervention to 2 postintervention. The number of seclusions on the designated unit declined from a mean of 4.33 preintervention to a mean of 1.667 postintervention.

CONCLUSION

These data suggest that an educational intervention to increase the knowledge of direct care staff in a broad range of de-escalation techniques resulted in a reduction in the use of restraint and seclusion. Ongoing training for nursing staff may reassure them of the efficacy of alternative methods for dealing with aggressive patients. [J Contin Educ Nurs. 2022;53(2):70-76.].

Healthcare professionals' and patients' attitudes toward the causes and management of aggression in Estonian psychiatric clinics: a quantitative cross-sectional comparative study

BACKGROUND

To enhance patient aggression management efficacy and to reduce the use of coercive interventions in inpatient psychiatric care, it is important to know the attitudes of all involved parties towards the aggression and its management.

AIMS

This study aimed to explore attitudes of the psychiatrists, nurses and inpatients toward the causes and management of patient aggression in Estonian psychiatric clinics. A frequency of aggressive behaviour experienced by professionals, the relationships between the attitudes, participation in coercion, and a frequency of aggression, were also identified.

METHODS

To assess attitudes towards the causes and management of patient aggression, the Management of Aggression and Violence Attitude Scale was implemented.

RESULTS

The survey comprised of 63 psychiatrists, 197 nurses and 199 inpatients. The patients and the professionals had similar as well as different attitudes toward aggression and its management. Patients expected professionals to take a more personal approach when aggression occurs; in some cases, allowing the patients to deal with negative emotions on their own but, if necessary, isolating or restraining the violent people.

CONCLUSIONS

There is a need of training programs that focus on dealing patient aggression to foster a culture of safe, patient-centred care and to reduce aggression in psychiatric clinics.

Professional quality of life and psychological resilience among psychiatric nurses

PURPOSE

The aim of this study was to determine the relationship between professional quality of life and psychological resilience in psychiatric nurses in Turkey.

DESIGN AND METHODS

A cross-sectional study was conducted with 100 psychiatric nurses in Turkey. Data were collected using the Professional Quality of Life Scale and the Connor-Davidson Resilience Scale.

FINDINGS

Correlations were observed between compassion satisfaction (CS) and burnout, CS and resilience, and in burnout and compassion fatigue (CF).

IMPLICATIONS FOR PRACTICE

Actions to improve resilience, prevent burnout, and reduce CF should be implemented.