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Price O, Armitage CJ, Bee P, Brooks H, Lovell K, Butler D, Cree L, Fishwick P, Grundy A, Johnston I, Mcpherson P, Riches H, Scott A, Walker L, Papastavrou Brooks C. De-escalating aggression in acute inpatient mental health settings: a behaviour change theory-informed, secondary qualitative analysis of staff and patient perspectives. BMC Psychiatry 2024; 24:548. [PMID: 39107709 PMCID: PMC11301843 DOI: 10.1186/s12888-024-05920-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 06/19/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND De-escalation is often advocated to reduce harm associated with violence and use of restrictive interventions, but there is insufficient understanding of factors that influence de-escalation behaviour in practice. For the first time, using behaviour change and implementation science methodology, this paper aims to identify the drivers that will enhance de-escalation in acute inpatient and psychiatric intensive care mental health settings. METHODS Secondary analysis of 46 qualitative interviews with ward staff (n = 20) and patients (n = 26) informed by the Theoretical Domains Framework. RESULTS Capabilities for de-escalation included knowledge (impact of trauma on memory and self-regulation and the aetiology and experience of voice hearing) and skills (emotional self-regulation, distress validation, reducing social distance, confirming autonomy, setting limits and problem-solving). Opportunities for de-escalation were limited by dysfunctional risk management cultures/ relationships between ward staff and clinical leadership, and a lack of patient involvement in safety maintenance. Motivation to engage in de-escalation was limited by negative emotion associated with moral formulations of patients and internal attributions for behaviour. CONCLUSION In addition to training that enhances knowledge and skills, interventions to enhance de-escalation should target ward and organisational cultures, as well as making fundamental changes to the social and physical structure of inpatient mental health wards. Psychological interventions targeting negative emotion in staff are needed to increase motivation. This paper provides a new evidence-based framework of indicative changes that will enhance de-escalation in adult acute mental health inpatient and PICU settings.
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Affiliation(s)
- Owen Price
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PL, England.
| | - Christopher J Armitage
- Manchester Centre for Health Psychology, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PL, England
- Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, Nelson Street, Manchester, M13 9NQ, England
- NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PL, England
| | - Penny Bee
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PL, England
| | - Helen Brooks
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PL, England
| | - Karina Lovell
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PL, England
| | - Debbie Butler
- Institute of Mental Health, University of Nottingham, Triumph Road, Nottingham, NG7 2TU, England
| | - Lindsey Cree
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PL, England
| | - Paul Fishwick
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PL, England
| | - Andrew Grundy
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PL, England
| | - Isobel Johnston
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PL, England
| | - Peter Mcpherson
- Division of Psychiatry, University College London, Tottenham Court Road, London, W1T 7NF, England
| | - Holly Riches
- Merseycare NHS Foundation Trust, Kings Business Park, Prescot, L34 1PJ, England
| | - Anne Scott
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Oxford Road, Manchester, M13 9PL, England
| | - Lauren Walker
- School of Health and Psychological Sciences, City, University of London, Northampton Square, London, EC1V 0HB, England
| | - Cat Papastavrou Brooks
- Population Health Sciences, Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, England
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Chavulak J, Smyth T, Sutcliffe N, Petrakis M. Staff Perspectives in Mental Health Research Regarding Restrictive Interventions: An Australian Scoping Review and Thematic Analysis. Behav Sci (Basel) 2023; 14:9. [PMID: 38247661 PMCID: PMC10812717 DOI: 10.3390/bs14010009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
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.
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Affiliation(s)
- Jacinta Chavulak
- Social Work Department, School of Primary and Allied Health Care, Caulfield Campus, Monash University, Caulfield East 3145, Australia;
- Mental Health Service, Alfred Health, Melbourne 3004, Australia; (T.S.); (N.S.)
| | - Terry Smyth
- Mental Health Service, Alfred Health, Melbourne 3004, Australia; (T.S.); (N.S.)
| | - Nicholas Sutcliffe
- Mental Health Service, Alfred Health, Melbourne 3004, Australia; (T.S.); (N.S.)
| | - Melissa Petrakis
- Social Work Department, School of Primary and Allied Health Care, Caulfield Campus, Monash University, Caulfield East 3145, Australia;
- Mental Health Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Australia
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Kodua M, Eboh WO. "It's not a nice thing to do, but…": A phenomenological study of manual physical restraint within inpatient adolescent mental health care. J Adv Nurs 2023; 79:4593-4606. [PMID: 37350022 DOI: 10.1111/jan.15742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 05/28/2023] [Accepted: 06/10/2023] [Indexed: 06/24/2023]
Abstract
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.
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Affiliation(s)
- Michael Kodua
- School of Health and Social Care, University of Essex, Colchester, UK
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Kodua M, Duxbury J, Eboh WO, Asztalos L, Tweneboa J. Healthcare staff's experiences of using manual physical restraint: A meta-synthesis review. Nurs Health Sci 2023; 25:271-289. [PMID: 37563098 DOI: 10.1111/nhs.13045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 07/18/2023] [Accepted: 07/28/2023] [Indexed: 08/12/2023]
Abstract
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.
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Affiliation(s)
- Michael Kodua
- School of Health and Social Care, University of Essex, Colchester, UK
| | - Joy Duxbury
- Faculty of Health & Education, Manchester Metropolitan University, Manchester, UK
| | | | - Lilla Asztalos
- School of Health and Social Care, University of Essex, Colchester, UK
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De Cuyper K, Vanlinthout E, Vanhoof J, van Achterberg T, Opgenhaffen T, Nijs S, Peeters T, Put J, Maes B, Van Audenhove C. Best practice recommendations on the application of seclusion and restraint in mental health services: An evidence, human rights and consensus-based approach. J Psychiatr Ment Health Nurs 2022; 30:580-593. [PMID: 36565433 DOI: 10.1111/jpm.12890] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/27/2022] [Accepted: 12/13/2022] [Indexed: 12/25/2022]
Abstract
UNLABELLED WHAT IS KNOWN ON THE SUBJECT?: Seclusion and restraint still regularly occur within inpatient mental health services. The Council of Europe requires the development of a policy on for instance age limits, techniques and time limits. However, they only define the outer limits of such a policy by indicating when rights are violated. Within these limits, many choices remain open. Staff and service managers lack clarity on safe and humane procedures. Research literature provides limited and contradictory insights on these matters. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The study resulted in 77 best practice recommendations on the practical application of restraint and seclusion as last resort intervention in inpatient youth and adult mental health services, including forensic facilities. To our knowledge, this is the first study in which the development of recommendations on this topic is not only based on scientific evidence, but also on an analysis of European human rights standards and consensus within and between expert-professionals and experts-by-experience. This approach allowed to develop for the first time recommendations on time limits, asking for second opinion, and registration of seclusion and restraint. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The 77 recommendations encourage staff to focus on teamwork, safety measures, humane treatment, age and time limits, asking for second opinion, observation, evaluation and registration when applying seclusion and restraint as last resort intervention. The implementation of the best practice recommendations is feasible provided that they are combined with a broad preventive approach and with collaboration between service managers, staff (educators) and experts-by-experience. Under these conditions, the recommendations will improve safety and humane treatment, and reduce harm to both service users and staff. ABSTRACT INTRODUCTION: Seclusion and restraint still regularly occur within inpatient mental health services. Professionals lack clarity on safe and humane procedures. Nevertheless, a detailed policy on for instance age limits, techniques and time limits is required. AIM We developed recommendations on the humane and safe application of seclusion, physical intervention and mechanical restraint in inpatient youth and adult mental health services, including forensic facilities. METHOD After developing a questionnaire based on a rapid scientific literature review and an analysis of human rights sources stemming from the Council of Europe, 60 expert-professionals and 18 experts-by-experience were consulted in Flanders (Belgium) through a Delphi-study. RESULTS After two rounds, all but one statement reached the consensus-level of 65% in both panels. The study resulted in 77 recommendations on teamwork, communication, materials and techniques, maximum duration, observation, evaluation, registration, second opinion and age limits. DISCUSSION Combining an evidence, human rights and consensus-based approach allowed for the first time to develop recommendations on time limits, asking for second opinion and registration. IMPLICATIONS FOR PRACTICE When combined with a preventive approach and collaboration between service managers, staff (educators) and experts-by-experience, the recommendations will improve safety and humane treatment, and reduce harm to service users and staff.
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Affiliation(s)
- Kathleen De Cuyper
- LUCAS - Centre for Care Research & Consultancy, University of Leuven, Leuven, Belgium
| | - Els Vanlinthout
- LUCAS - Centre for Care Research & Consultancy, University of Leuven, Leuven, Belgium
| | - Jasper Vanhoof
- Academic Centre of Nursing and Midwifery, University of Leuven, Leuven, Belgium
| | - Theo van Achterberg
- Academic Centre of Nursing and Midwifery, University of Leuven, Leuven, Belgium
| | - Tim Opgenhaffen
- Institute for Social Law, University of Leuven, Leuven, Belgium
| | - Sara Nijs
- Parenting and Special Education, University of Leuven, Leuven, Belgium
| | - Tine Peeters
- LUCAS - Centre for Care Research & Consultancy, University of Leuven, Leuven, Belgium
| | - Johan Put
- Institute for Social Law, University of Leuven, Leuven, Belgium
| | - Bea Maes
- Parenting and Special Education, University of Leuven, Leuven, Belgium
| | - Chantal Van Audenhove
- LUCAS - Centre for Care Research & Consultancy, University of Leuven, Leuven, Belgium
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