Staffing levels and seclusion use

Developing nurse-sensitive outcomes in acute inpatient mental health settings-A systematic review

BACKGROUND

While nurse-sensitive outcomes (NSOs) are well established in numerous health settings, to date there is no indicator suite of NSOs for inpatient mental health settings.

AIM

To assess the relationship between nursing variables and patient outcomes in acute inpatient mental health settings to determine which outcomes can be used as indicators of the quality of nursing care.

METHODS

Databases accessed were CINAHL, MEDLINE, PsycINFO and EMBASE, last searched in May 2022. The review followed the 2020 PRISMA checklist for systematic reviews. Papers published between 1995 and 2022, conducted in acute mental health care units were included. The quality of the studies was assessed using the Effective Public Health Practice Project Quality Assessment Tool. A meta-analysis was not possible because of the large number of variables and measurement inconsistencies.

RESULTS

A total of 57 studies were reviewed. Studies were categorised according to whether they found a significant or non-significant relationship between nurse variables and patient outcomes. Seven outcomes-aggression, seclusion, restraint, absconding, pro-re-nata medications, special observations and self-harm-were identified. For each outcome, there were significant findings for several nurse variables indicating that all included outcomes could be used as NSOs. However, evidence for aggression, seclusion and restraint use as suitable NSOs was more robust than the evidence for self-harm, absconding, pro-re-nata medications and special observations.

CONCLUSION

All the seven outcomes can all be used to develop an NSO indicator suite in mental health inpatient settings. More work is needed to establish high-quality studies to clearly demonstrate the relationship between these outcome measures and changes in nurse variables such as nurse staffing, skill mix, work environment, nurse education and nurse experience.

PATIENT AND PUBLIC CONTRIBUTION

Patient or public contribution was not possible because of the type of the variables being explored.

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.

Influence of nursing staff characteristics on seclusion in acute mental health care-A prospective two-year follow-up study

INTRODUCTION

Seclusion still occurs on mental health wards, despite absence of therapeutic efficacy and high risks of adverse patient effects. Literature on the effect of nursing teams, and the role of psychological characteristics in particular, on frequency of seclusion is scarce.

AIM

To explore the influence of demographic, professional or psychological, nursing team-level, and shift characteristics on the frequency of use of seclusion.

METHODS

Prospective two-year follow-up study.

RESULTS

We found that the probability of seclusion was lower when nursing teams with at least 75% males were on duty, compared to female only teams, odds ratio (OR = 0.283; 95% CrI 0.046-0.811). We observed a trend indicating that teams scoring higher on the openness personality dimension secluded less, (OR = 0.636; 95% CrI 0.292-1.156).

DISCUSSION

Higher proportions of male nurses in teams on duty were associated with lower likelihood of seclusion. We found an indication that teams with a higher mean openness personality trait tended to seclude less. These findings, if causal, could serve as an incentive to reflect on staff mix if circumstances demand better prevention of seclusion.

Nurse and patient factors: Predicting seclusion in adolescent psychiatric units

PROBLEM

Seclusion is considered a necessity when alternatives have failed. There is a consensus that seclusion has no therapeutic benefit, which justifies efforts to reduce the practice. This study aimed to identify nurse and patient variables that are predictive of seclusion on a large adolescent inpatient unit.

METHODS

Nested case controls were used to compare 72 afternoon shifts on which seclusion occurred to 216 afternoon shifts on which no seclusion occurred, between 2010 and 2013, at an Adolescent Psychiatric Inpatient Unit.

FINDINGS

Increased seclusion was predicted by a lower nurse to patient ratio, more male nurses on shift, fewer female nurses on shift, the presence of agency/temporary nurses on shift, greater combined years of mental health experience, and lower total HoNOSCA behavior subscale score. Unique predictors that increased risk of seclusion included greater number of male nurses and the presence of agency/temporary nurses, while a greater number of female nurses decreased risk of seclusion.

CONCLUSIONS

Nurses play a unique role in seclusion outcomes that are separate to patient-factors and act as both protective and risk factors for seclusion. Changes can be made to staffing to reduce seclusion and future research should investigate why these nurse-factors contribute to seclusion.

Influence of nursing staff attitudes and characteristics on the use of coercive measures in acute mental health services-A systematic review

WHAT IS KNOWN ON THE SUBJECT?: Aggressive behaviour is a major problem in clinical practice of mental health care and can result in the use of coercive measures. Coercive measures are dangerous for psychiatric patients and international mental healthcare works on the elimination of these interventions. There is no previous review that summarizes the attitude of nursing staff towards coercive measures and the influence of nursing staff characteristics on attitude towards and the use of coercive measures. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The attitude of nurses shifted from a therapeutic paradigm (coercive measures have positive effects on patients) to a safety paradigm (coercive measures are undesirable, but necessary for the wards' safety). Nurses express the need for less coercive interventions to prevent seclusion and restraint, but their perception of intrusiveness is influenced by how often they use specific coercive measures. The knowledge from scientific literature on the influence of nursing staff on coercive measures is highly inconclusive, although the feeling of safety of nurses might prove to be promising for further research. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There is need for increased attention specifically for the feeling of safety of nurses, to better equip nurses for their difficult work on acute mental health wards. ABSTRACT: Introduction The use of coercive measures generally has negative effects on patients. To help prevent its use, professionals need insight into what nurses believe about coercion and which staff determinants may influence its application. There is need for an integrated review on both attitude and influence of nurses on the use of coercion. Aim To summarize literature concerning attitude of nurses towards coercive measures and the influence of staff characteristics on the use of coercive measures. Method Systematic review. Results The attitude of nurses changed during the last two decades from a therapeutic to a safety paradigm. Nurses currently view coercive measures as undesirable, but necessary to deal with aggression. Nurses express the need for less intrusive interventions, although familiarity probably influences its perceived intrusiveness. Literature on the relation between staff characteristics and coercive measures is inconclusive. Discussion Nurses perceive coercive measures as unwanted but still necessary to maintain safety on psychiatric wards. Focussing on the determinants of perception of safety might be a promising direction for future research. Implications for practice Mental health care could improve the focus on the constructs of perceived safety and familiarity with alternative interventions to protect patients from unnecessary use of coercive interventions.

Deprivation of Liberty in Psychiatric Treatment: a Finnish perspective

This article is concerned with the deprivation of patients’ liberty while undergoing psychiatric treatment, with special reference to the situation in Finland. It is based on a review of Finnish law, health care statistics, and empirical and theoretical studies. Relevant research findings from other countries are also discussed. In Finland, it is required that patients are cared for by mutual understanding with themselves; coercive measures may be applied only if they are necessary for the treatment of the illness, or for safeguarding patients’ safety or the safety of others. Involuntary psychiatric hospitalization is closely regulated by the Mental Health Act. However, the rules concerning the deprivation of liberty during inpatient treatment (by seclusion, restraint and restricted leave) are formulated in very general terms. Therefore, Finnish psychiatric hospitals have their own policies concerning when and how seclusion may be used. The practice of seclusion and the use of restraint therefore vary among the psychiatric hospitals in Finland.

Do patient and ward-related characteristics influence the use of coercive measures? Results from the EUNOMIA international study

PURPOSE

This study aims to identify whether selected patient and ward-related factors are associated with the use of coercive measures. Data were collected as part of the EUNOMIA international collaborative study on the use of coercive measures in ten European countries.

METHODS

Involuntarily admitted patients (N = 2,027) were divided into two groups. The first group (N = 770) included patients that had been subject to at least one of these coercive measures during hospitalization: restraint, and/or seclusion, and/or forced medication; the other group (N = 1,257) included patients who had not received any coercive measure during hospitalization. To identify predictors of use of coercive measures, both patients' sociodemographic and clinical characteristics and centre-related characteristics were tested in a multivariate logistic regression model, controlled for countries' effect.

RESULTS

The frequency of the use of coercive measures varied significantly across countries, being higher in Poland, Italy and Greece. Patients who received coercive measures were more frequently male and with a diagnosis of psychotic disorder (F20-F29). According to the regression model, patients with higher levels of psychotic and hostility symptoms, and of perceived coercion had a higher risk to be coerced at admission. Controlling for countries' effect, the risk of being coerced was higher in Poland. Patients' sociodemographic characteristics and ward-related factors were not identifying as possible predictors because they did not enter the model.

CONCLUSIONS

The use of coercive measures varied significantly in the participating countries. Clinical factors, such as high levels of psychotic symptoms and high levels of perceived coercion at admission were associated with the use of coercive measures, when controlling for countries' effect. These factors should be taken into consideration by programs aimed at reducing the use of coercive measures in psychiatric wards.

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

Research shows that Indigenous Australians' suspicion and fear of being 'locked up' may influence mental health service avoidance. Given this, the aim of this study was to explore, by qualitative analysis of in-depth interviews (n = 3), how three Indigenous people experienced the controversial practice of seclusion. Hans-Georg Gadamer's phenomenology guided analysis of the material, and allowed narrated experiences to be understood within their cultural and historical context. Participants viewed seclusion negatively: police involvement in psychiatric care; perceptions of being punished and powerless; occasions of extreme use of force; and lack of care were prominent themes throughout the interviews. While power imbalances inherent in seclusion are problematic for all mental health clients, the distinguishing factor in the Indigenous clients' experience is that seclusion is continuous with the discriminatory and degrading treatment by governments, police, and health services that many Indigenous people have experienced since colonization. The participants' experiences echoed Goffman's findings that institutional practices act to degrade and dehumanize clients whose resulting conformity eases the work of nursing staff. While some nurses perceive that seclusion reduces clients' agitation, one must ask at what cost to clients' dignity, humanity, and basic human rights.

Nurses' attitudes to the use of seclusion: a review of the literature

Seclusion is now widely recognized as a coercive strategy with negative consequences for the consumers and staff involved. Nevertheless, this intervention continues to be used frequently in mental health services internationally. Due to their direct care role, nurses are commonly involved in the initiation or management of seclusion. Understanding nurses' attitudes to seclusion is therefore essential for the success of any attempts to reduce its use. A review of the literature was conducted using the search terms 'patient', 'seclusion', 'attitudes', 'nurses' and 'containment'. Twenty-eight articles which met the inclusion criteria were identified. Analysis of these articles identified six main themes: a necessary intervention; workplace culture; staff composition and experience; conflict; ethical considerations; and consumer characteristics. An overview of the literature is presented according to these main themes. The research suggests that most nurses support the continued use of seclusion as a strategy for the management of violence and aggression. A deeper understanding of the factors that influence attitudes is necessary if seclusion rates are to be effectively reduced.

Mental health service users' perceptions and experiences of sedation, seclusion and restraint

BACKGROUND

Sedation, seclusion or restraint are recognized methods of containing a person experiencing an acute psychotic episode with behavioural disturbance which has not responded to verbal or non-sedating pharmacological interventions. These interventions pose significant ethical and practical challenges to service providers who are responsible for safeguarding the human rights of mental health service users.

AIMS

In a collaborative two-phase study between mental health care providers and mental health service users, the perceptions and experiences of a group of service users who have been exposed to sedation, seclusion and restraint were explored.

METHOD

A focus group was conducted with eight service users. The content of the focus group was transcribed and themes were identified using thematic analysis. These were presented to a second focus group consisting of eight other service users for validation and comment. Based on the results of the focus groups, a questionnaire was developed and administered to a convenience sample of 43 service users in three localities.

RESULTS

Service users reported inadequate communication between them and service providers and perceived that their human rights had been infringed during acute episodes of illness.

METHODS

of containment were often seen as punitive rather than therapeutic. Sedation was most frequently used and was considered to be least distressing. Observing methods of forced/involuntary containment caused further distress.

CONCLUSIONS

There is a need to humanize service users' experiences during episodes of acute illness. Measures should include prevention of human rights abuses; minimization of isolation and distress; improvement of communication between service providers and service users; and promotion of attitudinal changes which reflect respect for other people's dignity.

Organizational and unit factors contributing to reduction in the use of seclusion and restraint procedures on an acute psychiatric inpatient unit

OBJECTIVE

The use of seclusion or restraint (S/R) as an emergency medical intervention to assist patients in regaining behavioral control continues to be an area of interest and concern for the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), consistent with the ongoing concerns in the medical, patient advocate, legislative and legal communities. This study examined unit characteristics and the use of S/R in a VA facility with a secured, acute mental health unit before and after the promulgation of the JCAHO 2000 standards for utilization of S/R for behavioral health reasons.

METHODS

Variables examined include patient acuity, patient census, number of admits, number of discharges, length of stay, number of nursing staff on duty, critical incidents and S/R hours per month.

RESULTS

Results indicated S/R use began showing a notable decrease corresponding to the time that senior unit management began discussions of the new JCAHO standards. These reductions maintained statistical significance even after controlling for changes in unit environmental variables.

The influence of staffing levels on the use of seclusion

This study focussed on the relationship between the use of seclusion and staff characteristics, such as number of nurses on shift, male-female staff ratio, level of education and level of work experience. A retrospective analysis of staff characteristics was applied to administrative data from ten wards in four mid-sized general psychiatric hospitals in the Netherlands. The data show that two variables were associated with seclusion rates: the male-female staff ratio and the variability in team's work experience. More female and less male nurses in a shift and less variability in team's work experience predicted an increase in seclusion rates.

Staff gender ratio and aggression in a forensic psychiatric hospital

Gender balance in acute psychiatric inpatient units remains a contentious issue. In terms of maintaining staff and patient safety, 'balance' is often considered by ensuring there are 'sufficient' male nurses present on each shift. In an ongoing programme of research into aggression, the authors investigated reported incidents of patient aggression and examined the gender ratio on each shift over a 6-month period. Contrary to the popular notion that a particular gender ratio might have some relationship with the likelihood of aggressive incidents, there was no statistically significant difference in the proportion of male staff working on the shifts when there was an aggressive incident compared with the shifts when there was no aggressive incident. Further, when an incident did occur, the severity of the incident bore no relationship with the proportion of male staff working on the shift. Nor did the gender of the shift leader have an impact on the decision to seclude the patient or the likelihood of completing an incident form following an aggressive incident. Staff confidence in managing aggression may be influenced by the presence of male staff. Further, aspects of prevention and management may be influenced by staff gender. However, results suggest there is no evidence that the frequency or severity of aggression is influenced by staff gender ratio.

Forensic psychiatric inpatient treatment: creating a therapeutic milieu

A functional therapeutic milieu in an adolescent forensic unit comprises far more elements than effective psychosocial treatments alone. In the psychosocial domain, this article discusses principles of therapeutic community, structure, predictability, therapeutic aggression management, and family work. A core element in all activities of an adolescent forensic unit is finding a balance between security and age-appropriate support for adolescent development.

Clinician perceptions of personal safety and confidence to manage inpatient aggression in a forensic psychiatric setting

Inpatient mental health clinicians need to feel safe in the workplace. They also require confidence in their ability to work with aggressive patients, allowing the provision of therapeutic care while protecting themselves and other patients from psychological and physical harm. The authors initiated this study with the predetermined belief that a comprehensive and integrated organizational approach to inpatient aggression was required to support clinicians and that this approach increased confidence and staff perceptions of personal safety. To assess perceptions of personal safety and confidence, clinicians in a forensic psychiatric hospital were surveyed using an adapted version of the Confidence in Coping With Patient Aggression Instrument. In this study clinicians reported the hospital as safe. They reported confidence in their work with aggressive patients. The factors that most impacted on clinicians' confidence to manage aggression were colleagues' knowledge, experience and skill, management of aggression training, use of prevention and intervention strategies, teamwork and the staff profile. These results are considered with reference to an expanding literature on inpatient aggression. It is concluded that organizational resources, policies and frameworks support clinician perceptions of safety and confidence to manage inpatient aggression. However, how these are valued by clinicians and translated into practice at unit level needs ongoing attention.

Staff and patient perceptions of seclusion: has anything changed?

BACKGROUND

Seclusion continues to be widely used in the management of disturbed behaviour in hospitalized patients. While early research on the topic highlighted significant differences in staff and patient perceptions, there are few recent data to indicate if these differences still exist.

AIM

This paper reports a study exploring the perceptions of both nursing staff and patients towards the reasons for seclusion; its effects; patients' feelings during seclusion; and possible changes to the practice.

METHODS

Sixty nursing staff and 29 patients who had experienced seclusion at three inpatient units in Queensland, Australia completed Heyman's Attitudes to Seclusion Survey.

RESULTS

The findings indicate that the two groups differed significantly on a number of the dimensions assessed. Nurses believed seclusion to be very necessary, not very punitive and a highly therapeutic practice that assisted patients to calm down and feel better. Patients, on the other hand, believed that seclusion was used frequently for minor disturbances and as a means of staff exerting power and control. Patients also believed that seclusion resulted in them feeling punished, and had little therapeutic value.

CONCLUSION

The disagreement between staff and patients highlights the need for greater dialogue between these groups. While nursing staff require greater understanding of how patients feel about seclusion, patients require information on why and how seclusion is implemented.

Misrepresenting random sampling? A systematic review of research papers in the Journal of Advanced Nursing

AIM

This paper discusses the theoretical limitations of the use of random sampling and probability theory in the production of a significance level (or P-value) in nursing research. Potential alternatives, in the form of randomization tests, are proposed.

BACKGROUND

Research papers in nursing, medicine and psychology frequently misrepresent their statistical findings, as the P-values reported assume random sampling. In this systematic review of studies published between January 1995 and June 2002 in the Journal of Advanced Nursing, 89 (68%) studies broke this assumption because they used convenience samples or entire populations. As a result, some of the findings may be questionable.

DISCUSSION

The key ideas of random sampling and probability theory for statistical testing (for generating a P-value) are outlined. The result of a systematic review of research papers published in the Journal of Advanced Nursing is then presented, showing how frequently random sampling appears to have been misrepresented. Useful alternative techniques that might overcome these limitations are then discussed. REVIEW LIMITATIONS: This review is limited in scope because it is applied to one journal, and so the findings cannot be generalized to other nursing journals or to nursing research in general. However, it is possible that other nursing journals are also publishing research articles based on the misrepresentation of random sampling. The review is also limited because in several of the articles the sampling method was not completely clearly stated, and in this circumstance a judgment has been made as to the sampling method employed, based on the indications given by author(s).

CONCLUSION

Quantitative researchers in nursing should be very careful that the statistical techniques they use are appropriate for the design and sampling methods of their studies. If the techniques they employ are not appropriate, they run the risk of misinterpreting findings by using inappropriate, unrepresentative and biased samples.

Patient concerns about seclusion: developing a leaflet

Seclusion continues to be used as a last resort in many acute in-patient mental health facilities, hence, mental health nurses must consider a range of strategies to improve seclusion practice. This article reviews selected literature to glean relevant information to provide to patients regarding seclusion protocols, rationales, and aims. Some postseclusion debriefing, nurse education, and organizational monitoring issues are also briefly discussed. The provision of supplementary written patient information about seclusion processes has the potential to decrease patient anxiety and fear. This initiative involves collaboration with consumer consultants to creatively develop effective solutions to some long-standing patient-identified problems associated with the experience of seclusion.

A synthesis of what we know about the use of physical restraints and seclusion with patients in psychiatric and acute care settings: 2003 update

PURPOSE

This article is an update of the January 19, 2000, Volume 7, Number 2 article of the synthesis of research findings on the use of restraint and seclusion with patients in psychiatric and acute care settings.

CONCLUSIONS

The little that is known about restraint/seclusion use with these populations is inconsistent. Attitudes and perceptions of patients, family, and staff differ. However, all patients had very negative feelings about both, whether they were restrained/secluded or observed by others who were not restrained. The reasons for restraint/seclusion use vary with no accurate use rate for either. What precipitates the use of restraint/seclusion also varies, but professionals claim they are necessary to prevent/treat violent or unruly behavior. Some believe seclusion/restraint is effective, but there is no empirical evidence to support this belief. Many less restrictive alternatives have been tested with varying outcomes. Several educational programs to help staff learn about different ways to handle violent/confused patients have been successful.

IMPLICATIONS

Until more is known about restraint/seclusion use from prospective controlled research, the goal to use least restrictive methods must be pursued. More staff educational programs must be offered and the evaluation of alternatives to restraint/seclusion pursued. When seclusion/restraint is necessary, it should be used less arbitrarily, less frequently, and with less trauma. As the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Health Care Financing Administration (HCFA) have prescribed, "Seclusion and restraint must be a last resort, emergency response to a crisis situation that presents imminent risk of harm to the patient, staff, or others" (p. 25) [99A].

Does seclusion have a role to play in modern mental health nursing?

The seclusion of patients with mental health problems is a controversial and emotive subject, and is a practice that was condemned by the Ashworth Inquiry (Department of Health (DoH), 1992). Despite this condemnation, it is still widely practised today. Opinions on the practice of seclusion vary greatly. Consequently, there is a need to review the theoretical and empirical literature regarding the use of seclusion in order to gain an understanding of the current state of the knowledge base in this substantive and controversial area. This article systematically reviews research published between 1994 and 1999 and discusses the findings under three headings: staff/patient attitudes to seclusion; the alternatives to seclusion; and the efficacy of seclusion. The reviewed material shows that seclusion is seen as a legitimate intervention by some hospital staff, but is "dreaded" by mental health patients. What is also evident is that seclusion is largely believed to be effective and that no true alternatives to its use exist. However, there appears to be no formal means of determining what constitutes an effective intervention in the management of violent incidents. Implications for practice and areas for future study are also discussed.

Experiences of coercion in psychiatric care as narrated by patients, nurses and physicians

AIM

The aim of the study was to increase understanding of psychiatric patients', nurses' and physicians' experience of coercion, in relation to their own and the other parties' experiences.

METHODS

Seven triads of patient, nurse and physician narrated their experiences of the same coercive event. The 21 interviews were analysed focusing on narrative elements.

RESULTS

The nurse and physician narratives revealed that they felt unable to connect with the patients, while the patients told us that they wanted more human contact with nurses and physicians. All three parties expressed the belief that interpersonal relationships and the human contact were important. The nurses and physicians stated that knowing the patient made them feel easier about using coercion and that their actions were less violating for the patient. The patients stated that human contact alleviated their feeling of discomfort and made them feel more secure when subjected to coercion.

CONCLUSION

The salient aspect described by all three parts was the importance of human contact and having a mutual relationship. These findings indicate a need for more dialogue between patients and staff. The dialogue should aim at making staff understand patients' feelings better regarding coercion and at informing the patients about the coercive measures.

Patients' perceptions of seclusion: a qualitative investigation

Twelve patients receiving acute in-patient psychiatric care in Queensland, Australia, participated in semi-structured interviews to elicit their perceptions of seclusion. All respondents had experienced time in seclusion within the 7 days prior to interview. Interviews were audiotaped, transcribed and analysed using content analysis. Five major themes emerged: use of seclusion, emotional impact, sensory deprivation, maintaining control and staff-patient interaction. The prevailing negativity towards seclusion underscores the need for ongoing critical review of its use. In particular, the relationship between patient responses to seclusion and the circumstances in which seclusion takes place requires greater consideration. Interventions such as providing information to patients about seclusion, increased interaction with patients during seclusion, attention to privacy and effective debriefing following seclusion may help to reduce the emotional impact of the practice.

Nurses' judgments regarding seclusion and restraint of psychiatric patients: a social judgment analysis

Clinical judgment of psychiatric nurses was investigated using judgment analysis within the framework of social judgment theory. Nine nurses at a short-term psychiatric care facility made recommendations concerning restraint and seclusion for 80 patients described on paper in terms of 17 characteristics (cues). Nurses generally favored close observation of patients over seclusion and restraint, and information about current behavior and functioning had more impact on nurses' judgments than did patient history. Nurses had good insight into the nature of their own judgments. However, individual differences in cue utilization and inconsistency in strategy usage led to disagreement among nurses about specific recommendations for particular patients. No one patient received identical recommendations from all nurses, and nurses agreed with each other on specific recommendations only about a third of the time. The lack of agreement has implications for development of staff training programs and further research on the clinical judgment processes of nurses.

The nurse's holding power: patterns of use in mental health

Implementation of the nurse's holding power (Section 5(4) of the Mental Health Act 1983) is an important, yet poorly researched aspect of mental health nursing practice. Data collected from the Mental Health Act records of all patients detained under Section 5(4) in one trust from 1983 to 1997 suggest that detainees generally came from the acute mental health services, were female, were detained by male registered mental nurses and were held for an average of 2 hours and 24 minutes before being placed on another section of the Mental Health Act. The use of Section 5(4) seems to be influenced by the time of day, but not the day of the week, or month of the year. Peaks of Section 5(4) usage corresponded to such factors as the changeover of shifts, the absence of medical staff, visiting time and medicine rounds. The importance of these findings for clinical practice is discussed.

Therapeutic interventions associated with seclusion of acutely disturbed individuals

The use of seclusion--i.e. placing an individual in a specially designed room with a locked door--continues to be an option in the management of mentally ill individuals whose behaviour is acutely disturbed, and who pose a personal and/or environmental threat. In a grounded theory study of psychiatric nurses' use of seclusion in two closed wards in a metropolitan teaching hospital in Australia, 'intervening' and 'mainstreaming' are the categories that describe nursing interventions developed from constant comparison of the data collected. Details of these interventions are presented, with reference to the skills that participants describe as necessary in the care of a mentally ill patient being secluded and then being re-integrated into ward life. Considerations for further study on the topic of seclusion are presented.