Variation in seclusion rates across New Zealand's specialist mental health services: Are sociodemographic and clinical factors influencing this?

Nurses' Perspectives on the Proposed Seclusion Elimination in Mental Health Wards

Managing consumers with challenging behaviours by way of secluding them has been practiced for centuries. Many countries have attempted to eliminate seclusion but with very limited success. The Victorian government in Australia has embarked on a plan to stop seclusion within the coming 10 years. A qualitative research design using a purposive cluster sampling technique was utilised to understand nurses' perceptions on attempts to eliminate seclusions in acute wards. Semi-structured interviews and a thematic analysis were used to reveal participants' perceptions. Analysis revealed six themes: personal views, staff skills/resources, safety concerns, stakeholders' influence, doubt about elimination and participants' recommendations. Participants were doubtful of seclusion elimination success if there were no major improvements in nurse security, infrastructure, funding and staffing. Further research is required to establish and develop effective alternatives to seclusion.

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.

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.

Risk factors associated with use of coercive practices in adult mental health inpatients: A systematic review

WHAT IS KNOWN ON THE SUBJECT?: Coercive practices such as restraint (physically holding a person) or seclusion (containing a person in locked room) are frequently used in mental health care. How often and which specific practices are used is not consistent across different healthcare systems, hospitals or wards. Internationally, there is agreement on the need to monitor and reduce the use of coercive practices. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The reviewed evidence suggests a number of different factors affect a person's risk of experiencing coercive practices, while admitted to a mental health ward. However, there is currently not enough high-quality research evidence to say which factors are most important or how they work to influence the likelihood of a person experiencing coercive practice. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: When carrying out risk assessments, mental health professionals must take into account that a number of different factors are important and explore these with the patient. Care plans aimed at minimizing the use of coercive practices, such as restraint, must be personalized and developed with the individual. ABSTRACT: Introduction Coercive practices, such as physical restraint and seclusion, are a common feature of all mental healthcare systems. However, there is considerable variation in their use, concern about their iatrogenic potential and agreement internationally on the need to monitor and reduce their use. Aims To examine the evidence concerning risk factors associated with use of coercive practices in adults admitted to inpatient psychiatric services. Method A systematic review, consistent with PRIMSA guidelines, of four databases (PsychINFO, Medline, CINHAL and Embase). Peer-reviewed, English language articles from database inception to February 2020 were included. Methodological quality was assessed using the Quality Assessment Tool for Quantitative Studies. Results Twenty studies met inclusion criteria. Risk factors examined in the studies organized around four categories: patient socio-demographic; patient clinical; staff; and organizational factors. Overall, methodological quality of papers was deemed weak, and there was insufficient evidence to support any singular risk factor. Discussion The reviewed evidence suggests risk of coercive practice in inpatient mental health settings is multifactorial. Further research to standardize concept definitions and elucidate the mechanisms behind variance in use is required. Implications for Practice Assessment of patients at risk of coercive practice must take a multifactorial approach.

"Our Patients Are Different": Predictors of Seclusion and Restraint in 31 Psychiatric Hospitals

BACKGROUND

Research in recent years has demonstrated that the use of coercive measures such as seclusion and restraint differs very much between hospitals within a country. In 2015, a central register for all coercive measures in the German federal state of Baden-Wuerttemberg has been established for 32 hospitals treating involuntary patients. The objective of the present study was to identify factors that determine the differences between these hospitals.

METHODS

Data on coercive measures and diagnoses from the central register in 2015-2017 were linked with structural data of the 32 hospitals and their supply areas.

RESULTS

On average, coercive measures were applied in 6.7% of cases (SD = 2.8%; Min-Max = 0.35-12.0%). The proportion of affected cases was significantly correlated with the proportion of involuntary patients (r = 0.56), the proportion of cases with affective or neurotic, stress-related and somatoform disorders (r = -0.42), number of hospital beds (r = 0.44), a sheltered home associated with the hospital (r = 0.43) and number of addiction counseling centers per 100,000 inhabitants in the service area (r = -0.39). The final regression model only included the proportion of involuntary cases as a significant predictor (standardized beta = 0.55, adjusted R ² = 0.27).

CONCLUSIONS

The predominating part of the considerable variance observed between hospitals could not be explained by structural variables. The proportion of involuntary patients had a significant impact, but a considerable amount of unexplained variance due to different practices within psychiatric hospitals remains.

Can the World Health Organisation's 'QualityRights' initiative help reduce coercive practices in psychiatry in Ireland?

The treatment of mental illness is undergoing a paradigm shift, moving away from involuntary treatments towards rights-based, patient-centred care. However, rates of seclusion and restraint in Ireland are on the rise. The World Health Organisation's QualityRights initiative aims to remove coercion from the practice of mental health care, in order to concord with the Convention on the Rights of Persons with Disabilities. The QualityRights initiative has recently published a training programme, with eight modules designed to be delivered as workshops. Conducting these workshops may reduce coercive practices, and four of the modules may be of particular relevance for Ireland. The 'Supported decision-making and advance planning' and the 'Legal capacity and the right to decide' modules highlight the need to implement the Assisted Decision-Making (Capacity) Act, 2015, while the 'Freedom from coercion, violence and abuse' and 'Strategies to end seclusion and restraint' modules describe practical alternatives to some current involuntary treatments.

The perspectives of a service user academic and a psychiatric trainee on engagement in supervision

This paper describes the perspectives of a service user academic and a psychiatric trainee in response to their engagement in service user supervision, now offered as part of our psychological medicine education, as a feature of an innovative service user-led, recovery and human rights focused, contact-based education programme. The supervision, being deliberately focused on exploring and addressing responsiveness to the traditionally underprivileged service user's perspective, and hence vastly different to clinical supervision, was acknowledged by the trainee as being of distinct value, translating into changes in practice, particularly in terms of addressing power imbalances, enhancing communication with patients, supporting recovery and enabling supported decision-making. The main barrier to implementation of such changes was identified as being the lack of support of senior clinicians. The active support and enablement of trainees who want to share and apply new perspectives, models and approaches being advocated, including through current training, would likely be of benefit to all.

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

AIM

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

BACKGROUND

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPACT

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