An examination of the incidence and nature of chemical restraint on adult acute psychiatric inpatient units in Adelaide, South Australia

Struggling with unnecessary suffering-Registered nurses' experiences of delayed decisions on treatment without consent in forensic psychiatric inpatient care

Chemical restraints are used in forensic psychiatric inpatient care, however with caution as it can feel like an assault against patients' integrity. When waiting for decisions on treatment without consent, nursing staff are expected to care for patients with severe mental ill-health without the use of medical treatment, often with a feeling of already having tried all other available means. Knowledge about how registered nurses experience such situations is sparse but could contribute to the development of both teamwork and nursing approaches that could mean reduced suffering for patients. The aim of this study was to describe registered nurses' experiences of delayed decisions on treatment without consent in forensic psychiatric inpatient care. Eleven semi-structured interviews were conducted with registered nurses working in forensic psychiatric units in Sweden. Data were analysed through qualitative content analysis. The result showed that experiences of treatment without consent were about striving to protect patients from harm, striving for collaboration during difficult circumstances and striving to do good. This was interpreted as a struggle with unnecessary suffering. For registered nurses to be able to handle such challenging situations and relieve suffering for patients, experience and master-level education in mental health nursing are highlighted. Another aspect that is highlighted is the importance of having consultants familiar with the circumstances at the unit. A method for joint reflection is suggested, to promote an open-minded work culture with a well-functioning decision-making process and ensure that both consultants and nursing staff have support.

Nurses' use of pro re nata medication in adult acute mental healthcare settings: An integrative review

This integrative review explores the current pro re nata (PRN) medication practice in acute adult mental health settings. PRN medication is commonly used in acute mental health settings but there is lack of evidence of effectiveness of this practice. PRN medications have a number of adverse effects and increase the risk of morbidity in patients with a mental illness. Articles were identified from MEDLINE, CINAHL, Scopus, PubMed, PsycINFO, and Web of Science database. The STROBE critical appraisal tool was used to evaluate the quality of evidence, and inductive thematic analysis was used to extract main themes. Five themes regarding prescription practices, poor documentation, reasons to administer, medication misuse, and insufficient use of non-pharmacological interventions emerged among the 12 eligible articles. The study identified PRN medication practice gaps in adult mental health settings included insufficient documentation practice, underuse of therapeutic non-pharmacological interventions, and significant variability in PRN medication practice across the mental health professionals due to different levels of knowledge and experience.

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.

Predictors of the use of restraint in inpatient psychiatric care among patients admitted via the emergency department

BACKGROUND

Coercive measures are associated with negative consequences for both patients and hospital staff. The aim of the study was to identify predictors for the use of restraints in the emergency department and in subsequent inpatient care.

METHOD

Retrospective routine clinical data of all patients admitted to the psychiatric departments of Vivantes Klinikum Am Urban in Berlin via the emergency department in 2019 was examined case-wise (n = 2584) as well as patient-wise (n = 2118).

RESULTS

Of all cases admitted via the emergency department, 195 cases (7.5%) experienced restraints and restraints combined with drug sedation during their inpatient treatment. Of the 2584 cases admitted via the emergency department, 195 cases (7.5%) experienced restraints and restraints combined with drug sedation during their inpatient treatment. These 195 cases experienced a total of 358 restraints and were distributed across 159 individuals. Multivariate regression analyses on patient-level show that age (p < .001), judicial placement (p < .001), and police referral in the presence of others (p < .001) had a statistically significant effect on the use of restraint.

DISCUSSION

The results indicate that certain patient characteristics increase the risk of restraints. A majority of the findings of this study underline previous research findings. However, ICD-10 diagnosis and gender do not prove to be significant variables, contrary to expectations based on previous.

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.

Key features of adolescent inpatient units and development of a checklist to improve consistency in reporting of settings

WHAT IS KNOWN ON THE SUBJECT?: Little is known about adolescent inpatient units, key features which define them, and how these essential services operate and deliver care. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Adolescent inpatient unit studies are limited in their descriptions of settings in terms of how they operate and key features. The proposed preliminary checklist is a practical tool to assist clinicians, policy makers, and researchers when reporting to ensure comprehensive descriptions of adolescent inpatient settings. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This could be used to inform service design processes for inpatient and other mental health service models which is of critical importance in the context of reforms and implementation of these in Australia currently. Greater attention to operational models, services, and philosophies of practice will improve reporting and allow for the advancement of knowledge, comparison of study results, and a clearer direction for mental health nursing clinicians and researchers. ABSTRACT: Introduction Adolescent inpatient units care for vulnerable population groups; however, little is known about how these essential services operate and deliver care. Aims To examine the descriptions of adolescent mental health inpatient units in Australian and international research publications and to identify key features which were used to define them. A secondary aim was to develop a checklist to improve consistency when reporting on the operations and services delivered within adolescent mental health inpatient units (both public and private). Methods Five electronic databases (CINAHL, MEDLINE, ERIC, EMBASE, and PsycINFO) were systematically searched. We included studies that provided descriptions of operations and services within adolescent inpatient units where participants had a mean age between 12 and 25. Narrative synthesis was used to explore the similarities and differences between descriptions of settings. Results Twenty-eight studies were identified, which varied in their descriptions of adolescent inpatient units, providing inconsistent information to inform best practice. Discussion Studies lack consistency and comprehensive detail when describing the operational models within inpatient units, making interpretation challenging. Consequently, a preliminary checklist is proposed to improve reporting of adolescent inpatient units.

Exploring the complexity of acute inpatient mental health nurses experience of chemical restraint interventions: Implications on policy, practice and education

Chemical restraint research is growing with multiple healthcare disciplines increasing focused on understanding uses, harms of restraint and restraint reduction in inpatient mental health settings. Despite increased restraint research relatively little is known about nurses' experiences of administering chemical restraint. The research question guiding this study was: what are mental health nurses' experiences of using chemical restraint interventions in times of behavioural emergency on adult inpatient acute mental health units? The purpose of the research was to understand direct care nurses' first-hand experiences in use of chemical restraint interventions. Eight adult acute inpatient mental health nurses were interviewed using hermeneutic phenomenological method. The aim of this paper to discuss three themes that emerged in the research which clearly highlight the complex ethical issues and education needs of mental health nurses who use chemical restraint: working within constraints, making medication choices, and transitioning from novice to expert. Research findings indicated a need for further focus on medication best practice, policy development and nurse education. These exploratory research findings can be used to both inform and challenge dominant inpatient mental health practice to guide nurses, health care leaders, and policy makers by increasing understanding of the complex ethical decision-making required for use of chemical restraint interventions. Education strategies can be developed from the findings which highlight integral ways that nurses make meaning in their administering of chemical restraint, and their accompanied insights into the complex clinical and ethical decision-making aspects involved in nursing care.

The experience and meaning of recovery-oriented practice for nurses working in acute mental health services

Since the 1990s, New Zealand mental health policy has shifted from a focus on the management of symptoms and risk to the recovery of psychological, social, cultural, and physical well-being. Despite a vision for recovery-oriented services being integrated within national and regional policies, there is growing concern that barriers to recovery-oriented service provision continue to exist. Such barriers include the attitudes, skills, and knowledge of front-line staff, as well as system issues. This study explored the experience and meaning of recovery-oriented practice for 10 nurses working in an acute inpatient mental health service. A phenomenological and hermeneutic lens was used to explore the nurses' experience of working in a recovery-focused manner alongside service users. Stories of practice were collected from participants through open-ended conversational interviews. Transcribed narratives were analysed to explore taken-for-granted aspects of working in acute mental health care and to uncover the meaning of being recovery-oriented in this setting. Findings revealed that although the experience and meaning of recovery-focused care varied among nurses, there were common elements in the practice accounts. The accounts highlighted the nurses' role in creating different therapeutic spaces to promote safety, relational commitment, and healing for service users. However, the nurses faced challenges to recovery-oriented care within the team hierarchical culture and the broader service systems. The nurses were, at times, fearless in advocating for service users and recognized that this was essential for developing recovery-focused services. The findings have implications for nursing practice, as well as training and service development.

Prevalence of the use of chemical restraint in the management of challenging behaviours associated with adult mental health conditions: A meta-synthesis

WHAT IS KNOWN ON THE SUBJECT?: The use of chemical restraint in emergency situations is to control aggression or violence to protect consumers and staff and is to be used as a last resort when all other behavioural control alternatives have been exhausted. Chemical restraint involves the use of medication. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first paper to systematically review the prevalence of the use of chemical restraint. The use of chemical restraint is common across emergency departments and acute psychiatric inpatient units worldwide. Consumers who are restrained are also likely to receive chemical restraint. The studies reviewed demonstrate that there is a need for more standardized data collection so that clearer comparisons can be made between healthcare settings and countries. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Implications of practice include the need to report adverse events post-chemical restraint as these can deleteriously affect a person's physical health. Identification of and staff education about first-line management techniques before chemical restraint is administered are significant to reduce its use. ABSTRACT: Introduction Chemical restraint is used to manage uncontrolled aggression, agitation or violent behaviours of consumers with mental health disorders admitted to acute psychiatric or emergency settings. Aim This systematic review aimed to synthesize the international prevalence of chemical restraint for non-consenting adults. Method PsycINFO, CINAHL, MEDLINE/PubMed and Google Scholar databases were searched for peer-reviewed literature published between January 1996 and July 2018. This paper reports on data extracted from retrospective audits of chemical restraint practice. Results Forty-eight papers were included. The median prevalence of use of any restraint was 21.2% (25th% 8.0 to 75th% 36.3). Median prevalence of people who were chemically restrained, of all people restrained in any manner, was 43.1% (25th% 22.9% to 75th% 70.7%). Of all people admitted to facility(ies), the median prevalence of chemical restraint was 7.4% (25th% 2.7 to 75th% 17.6). There was no statistically significant difference in any prevalence measure considering healthcare setting or country. There was a significant decrease over the review period in the use of any restraint, including chemical restraint. Discussion and implications for practice This is the first known comprehensive meta-view of chemical restraint use worldwide, highlighting the need for standardized data collection to enable comparisons between healthcare settings and countries. Relevance statement There is an international imperative to reduce or eliminate the use of coercive practices, such as physical and chemical restraint, in mental health care. This study provides important information for mental health nursing by synthesizing the international prevalence of chemical restraint for non-consenting adults. This meta-view of the worldwide use of chemical restraint can inform ongoing efforts to reduce its use.

Increased use of coercive procedures and prolonged hospitalization in compulsory admitted psychotic patients, who refuse antipsychotic medication

Objective: Current Danish legislation imposes that compulsory admitted psychotic patients have the right to refuse antipsychotic medication, which markedly delays pertinent medical treatment.Material and methods: In a retrospective, observational cohort study, we analyzed data from a 1-year period on 34 consecutively admitted patients with schizophrenia, who had been compulsory admitted due to need of treatment, or because they were judged to constitute an acute danger to themselves or others. We compared the use of other coercive procedures and hospitalization time.Results: Twenty-three patients accepted to commence antipsychotic treatment immediately, and 11 patients submitted an official complaint, which significantly delayed initiation of antipsychotic treatment (1 day ±0.9 versus 14 days ±10.1, p = 0.002). The 11 complaining patients were subjected to 6.8 times more coercive procedures of forced sedative medication compared to the 23 patients without delay (2.7 ± 2.3 episodes versus 0.4 ± 0.7 episodes, p = 0.007). Moreover, the treatment-delay prolonged duration of hospitalization by a factor 2.3 (73.3 ± 28.3 days versus 31.7 ± 22.0 days, p < 0.001).Conclusion: The current legislation intends to preserve patient rights and promote voluntary treatment alliance but may instead lead to prolonged hospitalization and increased use of other coercive measures such as forced sedative medication. Modification of current legislation may therefore be considered.

Role of security guards in Code Black events in medical and surgical settings: A retrospective chart audit

The prevalence of security guards in health care settings is growing worldwide. There is a need to explore and understand their role and actions to inform policy and training and support least restrictive practices in health care. The aim of this study was to conduct a retrospective chart audit of security guard logs to investigate security guard involvement in Code Blacks, called in emergency situations of personal threats including patient and/or visitor violence, in medical and surgical wards in a large metropolitan health network in South Australia. Security guards attended 1664 Code Blacks (0.63% of admissions) over the 2.5-year study period. Events were more frequently reported in medical than surgical wards. The most common reasons for security guard attendance were patients threatening/harming staff and patients threatening/harming themselves. The most frequent security guard actions were "Attend only/standby," "Physical restraint," and "Patient located and returned to the ward." The most frequent outcomes were physical restraint, chemical restraint, and de-escalation respectively. Results highlight the imperative that health services maintain and increase efforts to support least restrictive practice through policy directives and staff training.

The effectiveness of chemical restraint in managing acute agitation and aggression: A systematic review of randomized controlled trials

One approach to manage people with behaviours of concern including agitated or aggressive behaviours in health care settings is through the use of fast-acting medication, called chemical restraint. Such management often needs to be delivered in crisis situations to patients who are at risk of harm to themselves or others. This paper summarizes the available evidence on the effectiveness and safety of chemical restraint from 21 randomized controlled trials (RCTs) involving 3788 patients. The RCTs were of moderate to high quality and were conducted in pre-hospital, hospital emergency department, or ward settings. Drugs used in chemical restraint included olanzapine, haloperidol, droperidol, risperidol, flunitrazepam, midazolam, promethazine, ziprasidone, sodium valproate, or lorazepam. There was limited comparability between studies in drug choice, combination, dose, method of administration (oral, intramuscular, or intravenous drip), or timing of repeat administrations. There were 31 outcome measures, which were inconsistently reported. They included subjective measures of behaviours, direct measures of treatment effect (time to calm; time to sleep), indirect measures of agitation (staff or patient injuries, duration of agitative or aggressive episodes, subsequent violent episodes), and adverse events. The most common were time to calm and adverse events. There was little clarity about the superiority of any chemical method of managing behaviours of concern exhibited by patients in Emergency Departments or acute mental health settings. Not only is more targeted research essential, but best practice recommendations for such situations requires integrating expert input into the current evidence base.