Improving seclusion practice: implications of a review of staff and patient views

Effect of Seclusion on Mental Health Status in Hospitalized Psychiatric Populations: A Trial Emulation using Observational Data

The use of coercive practices, i.e., interventions against a person's will, is controversial. Recent observational studies highlighted their potential detrimental effects on patients' mental health, but this topic remains understudied. This study investigated the effect of a common coercive practice, seclusion (i.e., being locked in a closed room), on mental health using a trial emulation of observational data to allow causal inference. We used data from 1200 psychiatric inpatients, classified as being either secluded or non-secluded during their hospital stay. Inverse probability of treatment weighting was used to emulate the random assignment to the intervention. The primary outcome was the Health of the Nations Outcome Scales (HoNOS). The secondary outcome was the first item of the HoNOS, which focuses on overactive, aggressive, disruptive, or agitated behavior. Both outcomes were assessed at hospital discharge. There was a significant effect of seclusion with increases in both total HoNOS score (p = .002) and item 1 of the HoNOS (p = .01). Seclusion may have a negative causal effect of patients' mental health status and should therefore be avoided in mental health care settings. Training efforts should raise the awareness of the medical staff about potential adverse effects instead of therapeutic benefits.

Reducing use of seclusion on a male medium secure forensic ward

The reduction of restrictive practices is a priority for mental health inpatient services. Often such practices are considered to increase patients' feelings of anger, loneliness, hopelessness and vulnerability. Moreover, such approaches are counterintuitive to both recovery-orientated and trauma-informed practice.Our project, based in a male 15-bed secure forensic ward, aimed to reduce the duration (outcome measure) and frequency (balancing measure) of the use of seclusion by 10% over 6 months. Following the analysis of our local data systems and feedback from both patients and staff, we identified the high levels of use of seclusion, and reluctance to terminate it. These included a lack of awareness of the effective and appropriate use of such a facility, a hesitancy to use de-escalation techniques and an over-reliance on multidisciplinary team and consultant decision making.We subsequently designed and implemented three tests of change which reviewed seclusion processes, enhanced de-escalation skills and improved decision making. Our tests of change were applied over a 6-month period. During this period, we surpassed our original target of a reduction of frequency and duration by 10% and achieved a 33% reduction overall. Patients reported feeling safer on the ward, and the team reported improvements in relationships with patients.Our project highlights the importance of relational security within the secure setting and provides a template for other wards wishing to reduce the frequency and duration of seclusions.

The existential dimension of the experience of seclusion: a qualitative study among former psychiatric inpatients

BACKGROUND

Seclusion is a coercive measure - temporary confinement in an almost empty, non-stimulating room in a closed psychiatric admission ward to prevent (further) urgent danger due to a mental disorder. Although there is observational research about patients' behaviors during separation (e.g. hitting walls or doors, sleeping, or praying), research into the subjective and existential dimension of the experience of seclusion in psychiatry is rare.

AIM

Aim of the current study is to describe and analyze - using the theoretical lenses of Yalom (1980) and Jaspers (1919) - how clients experience their involuntary stay in a seclusion room in a closed psychiatric clinic in existential terms.

METHODS

A qualitative study was carried out among former clients (N = 10) who were asked, in retrospect, about their existential concerns in the seclusion room. In the thematic analysis, the main, deductive codes were theory based (Yalom, Jaspers), composed of subcodes that were inductively derived from the interviews.

RESULTS

The respondents affirmed the ultimate existential concerns about death (e.g. sensing to be dead already), lack of freedom (e.g. loss of agency), isolation (e.g. interpersonal, not able to speak, feeling an object) and meaninglessness. With respect to the latter, the respondents reported a rich variety of spiritual experiences (both negative, such as knowing to be in hell, as positive, hearing/imagining a comforting voice or noticing/imagining a scenery of nature in the room).

DISCUSSION

Although some experiences and behaviors may conflate with symptoms of psychosis, the participants generally expressed a relief about the ability to talk about their experiences. Sharing and discussing the existential experiences fits into the paradigm of psychiatric recovery and personalized care. Their intensity was obvious and might have warranted additional support by a chaplain or spiritual counselor in mental health care settings.

Treatment without consent in adult psychiatry inpatient units: a retrospective study on predictive factors

Background

Coercion is one of the most important challenges in mental health. In Switzerland, forced medication can be applied during an emergency (Art. 435 of the Civil Code) or over a longer period in case of endangerment of others or oneself (Art. 434). We aimed to analyze the predictors of this specific treatment without consent.

Methods

Forced medication prescriptions in the Division of Adult Psychiatry of the Geneva University Hospitals between 2018 and 2021 were retrospectively analyzed. Medication under Article 434 was the main outcome variable. Age, gender, admission mode, main diagnosis, and the Health of the Nation Outcome Scales (HoNOS) score at admission were considered as potential predictors. T-test and Pearson's chi-square test were used to compare continuous and categorical variables. A logistic regression was performed to find significant predictors of forced medication.

Results

Seventy-one out of 4,326 inpatients were subjected to forced medication under Art. 434. HoNOS global scores at admission were not significantly different in the forced medication group compared to the control group. Aggressive behavior was lower in the former at the univariate level. Forced medication was associated at the multivariate level with female gender, involuntary admission, and psychosis.

Conclusion

Women suffering from psychosis are more at risk of receiving involuntary and repeated medication. The risk of deterioration in psychosocial functioning or behavioral disorganization seems to be the main argument for this coercive measure. Future studies should focus on the patient's perception of this coercion to prevent it and improve adherence to care. Follow-up after discharge might be useful to evaluate a long-term benefit.

'Are they really allowed to treat me like that?' - A qualitative study to explore the nature of formal patient complaints about mental healthcare services in Sweden

The improvement of mental healthcare services requires patients' experiences to identify problems and possible deficits in care. In this study, we explored the nature and meaning of formal patient complaints about mental healthcare services in one region of Sweden using a descriptive design with a qualitative approach. A systematic random sample of 106 formal patient complaints about mental healthcare services in 1 Swedish county was selected and analysed thematically, based on descriptive phenomenology. Themes identified were: lack of access to mental healthcare services and specialist treatment, problems related to unmet needs and difficulties with healthcare staff, insufficient care and treatment and lack of continuity in care, and experiences of not been taken seriously or feeling abused by staff. The vulnerability of patients already in the system is a greater issue than realized. The human right to health and the healthcare of patients with mental ill health can be strengthened by increased access to care, listening to patients properly, and delivering continuity in care.

Measuring Seclusion in Psychiatric Intensive Care: Development and Measurement Properties of the Clinical Seclusion Checklist

Background: Acute psychiatric units in general hospitals must ensure that acutely disturbed patients do not harm themselves or others, and simultaneously provide care and treatment and help patients regain control of their behavior. This led to the development of strategies for the seclusion of a patient in this state within a particular area separated from other patients in the ward. While versions of this practice have been used in different countries and settings, a systematic framework for describing the various parameters and types of seclusion interventions has not been available. The aims of the project were to develop and test a valid and reliable checklist for characterizing seclusion in inpatient psychiatric care. Methods: Development and testing of the checklist were accomplished in five stages. Staff in psychiatric units completed detailed descriptions of seclusion episodes. Elements of seclusion were identified by thematic analysis of this material, and consensus regarding these elements was achieved through a Delphi process comprising two rounds. Good content validity was ensured through the sample of seclusion episodes and the representative participants in the Delphi process. The first draft of the checklist was revised based on testing by clinicians assessing seclusion episodes. The revised checklist with six reasons for and 10 elements of seclusion was tested with different response scales, and acceptable interrater reliability was achieved. Results: The Clinical Seclusion Checklist is a brief and feasible tool measuring six reasons for seclusion, 10 elements of seclusion, and four contextual factors. It was developed through a transparent process and exhibited good content validity and acceptable interrater reliability. Conclusion: The checklist is a step toward achieving valid and clinically relevant measurements of seclusion. Its use in psychiatric units may contribute to quality assurance, more reliable statistics and comparisons across sites and periods, improved research on patients' experiences of seclusion and its effects, reduction of negative consequences of seclusion, and improvement of psychiatric intensive care.

Seclusion in an enriched environment versus seclusion as usual: A quasi-experimental study using mixed methods

Background

For patients, seclusion during psychiatric treatment is often a traumatic experience. To prevent such experiences, adjustments in the design of seclusion rooms have been recommended.

Methods

As there have been no empirical studies on the matter, we used a quasi-experimental design to compare the experiences in seclusion of two groups of patients: 26 who had been secluded in a room designed according to the principles of healing environment, a so called ‘Enriched Environment Seclusion room’ (EES), and 27 who had been secluded in a regular seclusion (RS) room. The enrichment included audio-visual facilities, a fixed toilet, a couch and a self-service system to adjust light, colour, blinds and temperature according to the patient’s preferences. Insight into their experiences was obtained using the Patient View-of-Seclusion Questionnaire, which comprises nine statements on seclusion, supplemented with open-ended questions.

Results

The responses regarding seclusion experiences between the two groups did not differ significantly (U = 280.00, p = .21, r = -.17). Although those who had been secluded in the specially designed room had greatly appreciated the opportunities for distraction, and those who had been secluded in a regular seclusion room expressed the need for more distracting activities during seclusion, both groups described seclusion as a dreadful experience. If seclusion cannot be avoided, patients recommend facilities for distraction (such as those provided in an enriched environment seclusion room) to be available.

Conclusion

Whatever the physical environment and facilities of a seclusion room, we may thus conclude that seclusion is a burdensome experience.

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.

Influence of Organizational Climate and Clinician Morale on Seclusion and Physical Restraint Use in Inpatient Psychiatric Units

OBJECTIVES

Reducing seclusion and restraint use is a prominent focus of efforts to improve patient safety in inpatient psychiatry. This study examined the poorly understood relationship between seclusion and restraint rates and organizational climate and clinician morale in inpatient psychiatric units.

METHODS

Facility-level data on hours of seclusion and physical restraint use in 111 U.S. Department of Veterans Affairs (VA) hospitals in 2014 to 2016 were obtained from the Centers for Medicare & Medicaid Services. Responses to an annual census survey were identified for 6646 VA inpatient psychiatry clinicians for the same period. We examined bivariate correlations and used a Poisson model to regress hours of seclusion and restraint use on morale and climate measures and calculated incident rate ratios (IRRs).

RESULTS

The average physical restraint hours per 1000 patient hours was 0.33 (SD, 1.27; median, 0.05). The average seclusion hours was 0.31 (SD, 0.84; median, 0.00). Physical restraint use was positively associated with burnout (IRR, 1.76; P = 0.04) and negatively associated with engagement (IRR, 0.22; P = 0.01), psychological safety (IRR, 0.48; P < 0.01), and relational climate (IRR, 0.69; P = 0.04). Seclusion was positively associated with relational climate (IRR, 1.69; P = 0.03) and psychological safety (IRR, 2.12; P = 0.03). Seclusion use was also nonsignificantly associated with lower burnout and higher engagement.

CONCLUSIONS

We found significant associations between organizational climate, clinician morale, and use of physical restraints and seclusion in VA inpatient psychiatric units. Health care organization leadership may want to consider implementing a broader range of initiatives that focus on improving organizational climate and clinician morale as one way to improve patient safety.

Coercion in psychiatry: A cross-sectional study on staff views and emotions

WHAT IS KNOWN ON THE SUBJECT?: Coercive interventions (CI) in emergency psychiatry face increasing criticism, as they can be an emotional, even traumatic event for all persons involved. They are thus considered the last resort. The use of coercive interventions differs widely with regard to type and frequency of measures across different countries and institutions. Individual staff characteristics, such as attitudes towards coercion, may play a vital role in the management of aggression. Little is known about the influence of emotions of staff members on CI, but they are likely to play an important role. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Most staff members surveyed had a rather critical view of coercion and considered it a "necessary evil." Staff members with the most work experience had a more critical view of coercion in comparison with less experienced staff. Nurses rated coercion more positively than did psychiatrists or psychologists. Emotions play an important role in decision-making processes. The current study systematically asked for accompanying emotions during the application of CI and looked for individual differences. A majority of the participants experienced compassion; about half felt helplessness, grief or anxiety. Almost 20% stated that they felt a sense of power. Older staff members more often felt anger or guilt; women felt less power than men did. Nurses felt more desperation than other occupational groups. Staff members consider reflective interventions, such as team supervisions or post-seclusion/restraint debriefings with the patient, as important. Nevertheless, only half reported that these interventions are carried out routinely. Staff members believe that certain risk factors (including stress, low staffing, a fully occupied ward and the presence of particular staff members) enhance the probability of CI. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: To reduce the use of coercive interventions, we recommend that psychiatric teams include highly experienced staff members as work experience has a positive effect on the attitudes towards coercive interventions. Structured post-seclusion/restraint debriefings and team supervisions are considered helpful by staff members and are relatively easy to implement on acute wards. Enhancing staff members' ability to reflect on their own attitudes, emotions and actions is likely to reduce coercive interventions. ABSTRACT: Introduction Little is known about staff attitudes towards coercive interventions (CI) and emotions accompanying these measures. Aim The current study assessed attitudes, views on reflective interventions and accompanying emotions of different occupational groups towards CI, as well as factors, that increase the probability of CI. Method Staff members (N = 138) of a large psychiatric hospital in Germany were assessed using the Staff Attitude to Coercion Scale (SACS) and newly developed items assessing staff members' emotions and views on coercion. Results Experienced staff members were most critical of coercion. Nurses rated coercion significantly more positively than other staff. A majority experienced compassion; about half felt helplessness, grief or anxiety. Almost 20% felt a sense of power. Nurses felt the most desperation. Participants strongly desired reflective measures such as post-seclusion/restraint debriefings with patients. According to staff members, stress on the wards and low staffing increases the probability of CI. Discussion The study assessed accompanying emotions during the application of CI. Attitudes towards coercion and emotions are associated with individual staff characteristics (e.g. profession, work experience). Implications The presence of experienced staff members may help prevent CI. Staff consider reflective interventions helpful in reducing CI.

[Mental health and human rights: The experience of professionals in training with the use of mechanical restraints in Madrid, Spain]

Mechanical restraint is a coercive procedure in psychiatry, which despite being permitted in Spain, raises significant ethical conflicts. Several studies argue that non-clinical factors - such as professionals' experiences and contextual influences - may play a more important role than clinical factors (diagnosis or symptoms) in determining how these measures are employed. The aim of this study is to understand how the experiences of mental health professionals in training relate to the use of mechanical restraints in Madrid's mental health network. Qualitative phenomenological research was conducted through focus groups in 2017. Interviews were transcribed for discussion and thematic analysis with Atlas.ti. Descriptive results suggest that these measures generate emotional distress and conflict with their role as caregivers. Our findings shed light on different factors related to their experiences and contexts that are important in understanding the use of mechanical restraint, as well as the contradictions of care in clinical practice.

Use of coercion prevention tools in Finnish psychiatric wards

Inpatient violence is a widespread problem in psychiatric wards and has often serious consequences. Literature indicates that de-escalation techniques are the recommended first-line intervention for managing violence, are widely used to reduce it, and restrictive practices in mental health settings. However, these techniques and models are not used at the optimum frequency and/or important factors are limiting their use and effectiveness. We aimed to determine what kind of de-escalation methods are used to reduce violence and coercion in Finnish psychiatric hospitals. Descriptive qualitative research using semi-structured questionnaires and Framework Analysis was used. The results of the study are reported in quantitative terms. A survey of psychiatric wards (N = 65) in Finland's hospital districts (n = 16) was conducted in the Autumn of 2019 to find out which de-escalation models are used. Finnish psychiatric wards use both the Safewards and Six Core Strategies models to reduce violence and the use of restrictive practices. Half of the hospitals used interventions and strategies from both models. Violence preventive methods are widely used in mental health settings in Finland. These interventions and models cover the organization, leadership, and patient perspectives to improve safety and decrease coercion actions in psychiatric wards.

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.

Violence Factors and Debriefing in Psychiatric Inpatient Care: A Review

The aim of the current review was to identify, analyze, and synthesize the available research on violence factors in psychiatric care and the potential of debriefing to reduce the incidence of violence necessitating coercive measures. A two-part electronic search was conducted using multiple databases. Part 1 focused on reviews and meta-analyses relating to violence factors published between 2007 and 2017. Part 2 focused on articles on debriefing published after 2000. Two hundred ninety-five articles on violence factors and debriefing were identified, from which 39 publications were selected for detailed analysis. Results indicate that patient characteristics, management, staff approaches, and the ward environment are influencers that may trigger violent incidents. Several violence factors in psychiatric care have been identified. Nursing communication, leadership, and debriefing are among the most effective ways of reducing violence in psychiatric care. [Journal of Psychosocial Nursing and Mental Health Services, 58(5), 39-49.].

Ethical and Practical Issues in Video Surveillance of Psychiatric Units

OBJECTIVES

Video surveillance is used in inpatient psychiatry in many countries and institutions. However, its use varies considerably because of a lack of research, discussion, and agreement on best practice. This review provides an overview of current issues in the use of video surveillance in psychiatry, with a focus on ethical questions and their practical implications.

METHODS

A narrative review of literature on video surveillance in psychiatry was conducted. References were identified through searches of PubMed, CINAHL, MEDLINE, PsycINFO, and Google Scholar for articles published before December 2018. Sixteen articles in English and German were reviewed.

RESULTS

The ethical challenges and practical implications differ between surveillance of public spaces versus private areas, such as bedrooms or seclusion rooms. The most common reason for video surveillance was to increase security and safety. However, empirical evidence suggests that it is not useful in increasing security of shared spaces on psychiatric wards. Some evidence exists for clinical benefits of video surveillance in private spaces (e.g., allowing patients to sleep undisturbed). Video surveillance can increase patients' choices regarding monitoring options. The main ethical conflict lies in balancing patients' autonomy and privacy versus patient and staff security and safety.

CONCLUSIONS

Whether video monitoring is used in the most effective and ethical manner needs to be reconsidered. Available evidence does not support its use as a security measure. More research is needed to evaluate the benefits, risks, and best practices of using video monitoring for patient observation, with consideration given to increasing the role of patient consent.

Psychiatric nursing managers' attitudes towards containment methods in psychiatric inpatient care

AIMS

This research was conducted to examine psychiatric nursing managers' attitudes towards containment methods.

BACKGROUND

Nursing management is regarded as a key issue in the reduction of coercion and containment. However, there has been little research on managers' attitudes towards containment methods.

METHODS

This descriptive, cross-sectional study utilized a survey design. Finnish inpatient psychiatric nursing managers (n = 90) completed the Attitudes to Containment Measures Questionnaire (ACMQ). The results were described with statistics, and the associations between attitudes and background variables were analysed using parametric tests.

RESULTS

Psychiatric nursing managers had the most negative attitude towards net bed and mechanical restraint, and the most positive attitudes towards as necessary medication and intermittent observation. A few associations were discovered between attitudes and background variables such as gender and number of employees.

CONCLUSIONS

In general, Finnish psychiatric nursing managers' attitudes towards containment methods seem to be quite negative, but more research is needed.

IMPLICATIONS FOR NURSING MANAGEMENT

This study provides fresh and unique data on the attitudes of psychiatric nursing managers towards containment methods. Managers' attitudes are important because of their ability to encourage investment in coercion reduction by nursing staff.

Using patient experience data to support improvements in inpatient mental health care: the EURIPIDES multimethod study

Background

All NHS providers collect data on patient experience, although there is limited evidence about what to measure or how to collect and use data to improve services. We studied inpatient mental health services, as these are important, costly and often unpopular services within which serious incidents occur.

Aims

To identify which approaches to collecting and using patient experience data are most useful for supporting improvements in inpatient mental health care.

Design

The study comprised five work packages: a systematic review to identify evidence-based patient experience themes relevant to inpatient mental health care (work package 1); a survey of patient experience leads in NHS mental health trusts in England to describe current approaches to collecting and using patient experience data in inpatient mental health services, and to populate the sampling frame for work package 3 (work package 2); in-depth case studies at sites selected using the work package 2 findings, analysed using a realist approach (work package 3); a consensus conference to agree on recommendations about best practice (work package 4); and health economic modelling to estimate resource requirements and potential benefits arising from the adoption of best practice (work package 5). Using a realist methodology, we analysed and presented our findings using a framework based on four stages of the patient experience data pathway, for which we coined the term CRAICh (collecting and giving, receiving and listening, analysing, and quality improvement and change). The project was supported by a patient and public involvement team that contributed to work package 1 and the development of programme theories (work package 3). Two employed survivor researchers worked on work packages 2, 3 and 4.

Setting

The study was conducted in 57 NHS providers of inpatient mental health care in England.

Participants

In work package 2, 47 NHS patient experience leads took part and, in work package 3, 62 service users, 19 carers and 101 NHS staff participated, across six trusts. Forty-four individuals attended the work package 4 consensus conference.

Results

The patient experience feedback cycle was rarely completed and, even when improvements were implemented, these tended to be environmental rather than cultural. There were few examples of triangulation with patient safety or outcomes data. We identified 18 rules for best practice in collecting and using inpatient mental health experience data, and 154 realist context–mechanism–outcome configurations that underpin and explain these.

Limitations

The study was cross-sectional in design and we relied on examples of historical service improvement. Our health economic models (in work package 5) were therefore limited in the estimation and modelling of prospective benefits associated with the collection and use of patient experience data.

Conclusions

Patient experience work is insufficiently embedded in most mental health trusts. More attention to analysis and interpretation of patient experience data is needed, particularly to ways of triangulating these with outcomes and safety data.

Future work

Further evaluative research is needed to develop and evaluate a locally adapted intervention based on the 18 rules for best practice.

Study registration

The systematic review (work package 1) is registered as PROSPERO CRD42016033556.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 21. See the NIHR Journals Library website for further project information.

Moral Experiences of Crisis Management in a Child Mental Health Setting: A Participatory Hermeneutic Ethnographic Study

Restraints and seclusion are routinely used in child mental health settings for conflict and crisis management, but raise significant ethical concerns. Using a participatory hermeneutic ethnographic framework, we studied conflict and crisis management in a child mental health setting offering care to children aged 6-12 years old in Quebec, Canada. The use of this framework allowed for an in-depth examination of the local imaginaries, of what is morally meaningful to the people in the setting, in addition to institutional norms, structures and practices. Data collection involved participant observation, interviews, and documentation review, with an interpretive framework for data analysis. We argue that the prevalent view of children shared by staff members as "incomplete human becomings" led to the adoption and legitimization of authoritative norms, structures and practices guided largely by a behavioral approach, which sometimes led to an increased use of control measures for reasons other than imminent harm. Children experienced these controlling practices as abusive and hindering the development of trusting relationships, which impeded the implementation of more collaborative approaches staff members sought to put in place to prevent the use of control measures. Study results are discussed in light of conceptions of children as moral agents.

Ethical challenges of seclusion in psychiatric inpatient wards: a qualitative study of the experiences of Norwegian mental health professionals

BACKGROUND

Seclusion is an invasive clinical intervention used in inpatient psychiatric wards as a continuation of milieu therapy with vast behavioural implications that raise many ethical challenges. Seclusion is in Norway defined as an intervention used to contain the patient, accompanied by staff, in a single room, a separate unit, or an area inside the ward. Isolation is defined as the short-term confinement of a patient behind a locked or closed door with no staff present. Few studies examine how staff experiences the ethical challenges they encounter during seclusion. By making these challenges explicit and reflecting upon them, we may be able to provide better care to patients. The aim of this study is to examine how clinical staff in psychiatric inpatient wards describes and assess the ethical challenges of seclusion.

METHODS

This study was based on 149 detailed written descriptions of episodes of seclusion from 57 psychiatric wards. A descriptive and exploratory approach was used. Data were analysed using qualitative content analysis.

RESULTS

The main finding is that the relationship between treatment and control during seclusion presents several ethical challenges. This is reflected in the balance between the staff's sincere desire to provide good treatment and the patients' behaviour that makes control necessary. Particularly, the findings show how taking control of the patient can be ethically challenging and burdensome and that working under such conditions may result in psychosocial strain on the staff. The findings are discussed according to four core ethical principles: autonomy, beneficence, non-maleficence, and justice.

CONCLUSION

Ethical challenges seem to be at the core of the seclusion practice. Systematic ethical reflections are one way to process the ethical challenges that staff encounters. More knowledge is needed concerning the ethical dimensions of seclusion and alternatives to seclusion, including what ethical consequences the psychosocial stress of working with seclusion have for staff.

What are adult psychiatric inpatients' experience of seclusion: A systematic review of qualitative studies

WHAT IS KNOWN ON THE SUBJECT?: Seclusion involves isolating a patient in a room away from other patients in order to contain aggressive behaviour, and it is used in psychiatric hospitals. Research has found that seclusion is often viewed by patients as negative; however, there is limited in-depth understanding of the deeply personal experience. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This systematic review found that the published research may have flaws with the quality of analysis, mainly due to limited researcher reflexivity. The review of qualitative research revealed that during seclusion, patients feel vulnerable, neglected and abused, disconnected from the experience and that it is dangerous to their mental health. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: For clinicians facilitating the seclusion process to use their therapeutic skills to provide patients with a sense of being cared for. For clinical supervision to allow space to explore interpersonal dynamics during seclusion in order to enhance therapeutic staff-patient interaction. Abstract Introduction There is limited understanding of patients' seclusion experience. A 2013 systematic review provides some insight; however, more knowledge is required in order to improve patient care. This is a systematic review of qualitative research into the patient experience of seclusion. The qualitative focus enables the phenomena to be the central focus. Question "What are adult psychiatric inpatients' experience of seclusion?" and "What is the quality of the applicable research?" Method Electronic searches for qualitative research published between 2006 and 2017 were undertaken. Data were excluded if it was not explicitly related to seclusion. Research was appraised using three standardized appraisal criterion. Themes were generated through thematic synthesis. Results Eight papers met inclusion criteria; four had been translated into English. Four themes were identified: "feeling vulnerable," "feeling neglected and abused," "disconnecting" and "seclusion is dangerous to mental health." Participants felt vulnerable and without control. They experienced staff and room as neglectful and abusive. Participants mentally disconnected. The experience threatened participants' mental health. Discussion Participants' experience is an amalgamation of interpersonal experience and the environment. Disconnecting may be a coping strategy. Implications for practice The findings have implications for seclusion practice, staff training and clinical supervision. Specific attention needs to be paid to the staff-patient interaction.

Assessment of Risk for Seclusion Among Forensic Inpatients: Validation and Modification of the Risk of Administrative Segregation Tool (RAST)

Seclusion is used in psychiatric care to protect patients and staff or to manage aggression but may have adverse effects. The ability to identify at-risk patients could help reduce seclusion. This study tested the Risk of Administrative Segregation Tool's (RAST) ability to predict any seclusions among 229 male forensic inpatients followed for up to 1 year of hospitalization, and days spent secluded, controlling for length of stay. RAST scores were lower than in correctional samples. The RAST did not predict seclusions in Year 1, but modification of three items to fit the forensic population (RAST-F) offered a small improvement. Among 62 patients hospitalized for more than 1 year, the RAST significantly predicted seclusions in Year 2, and the modifications improved prediction. The present modest findings support the RAST's potential to help identify patients most in need of clinical efforts to avert seclusion. Replication in larger samples, including female patients, is needed.

Experiences of in-patient mental health services: systematic review

BACKGROUND

In-patients in crisis report poor experiences of mental healthcare not conducive to recovery. Concerns include coercion by staff, fear of assault from other patients, lack of therapeutic opportunities and limited support. There is little high-quality evidence on what is important to patients to inform recovery-focused care.AimsTo conduct a systematic review of published literature, identifying key themes for improving experiences of in-patient mental healthcare.

METHOD

A systematic search of online databases (MEDLINE, PsycINFO and CINAHL) for primary research published between January 2000 and January 2016. All study designs from all countries were eligible. A qualitative analysis was undertaken and study quality was appraised. A patient and public reference group contributed to the review.

RESULTS

Studies (72) from 16 countries found four dimensions were consistently related to significantly influencing in-patients' experiences of crisis and recovery-focused care: the importance of high-quality relationships; averting negative experiences of coercion; a healthy, safe and enabling physical and social environment; and authentic experiences of patient-centred care. Critical elements for patients were trust, respect, safe wards, information and explanation about clinical decisions, therapeutic activities, and family inclusion in care.

CONCLUSIONS

A number of experiences hinder recovery-focused care and must be addressed with the involvement of staff to provide high-quality in-patient services. Future evaluations of service quality and development of practice guidance should embed these four dimensions.Declaration of interestK.B. is editor of British Journal of Psychiatry and leads a national programme (Synergi Collaborative Centre) on patient experiences driving change in services and inequalities.

Preventing and Reducing Coercive Measures-An Evaluation of the Implementation of the Safewards Model in Two Locked Wards in Germany

Introduction: Aggression and violence are highly complex problems in acute psychiatry that often lead to the coercive interventions. The Safewards Model is an evidence-informed conflict-reduction strategy to prevent and reduce such incidents. The aim of this study was to evaluate the implementation of this model with regard to coercive interventions in inpatient care. Materials and Methods: We evaluated outcomes of the implementation of the Safewards Model in two locked psychiatric wards in Germany. Frequency and duration of coercive interventions applied during a period of 10 weeks before and 10 weeks after the implementation period were assessed through routine data. Fidelity to the Safewards Model was assessed by the Organization Fidelity Checklist. Results: Fidelity to the Safewards Model was high in both wards. The overall use of coercive measures differed significantly between wards [case-wise: χ2 (1, n = 250) = 35.34, p ≤ 0.001; patient-wise: χ2 (1, n = 103) = 21.45, p ≤ 0.001] and decreased post-implementation. In one ward, the number of patients exposed to coercive interventions in relation to the overall number of admissions decreased significantly [χ2 (1, 182) = 9.30, p = 0.003]. Furthermore, the mean duration of coercive interventions overall declined significantly [U(55,21) = -2.142, p = 0.032] with an effect size of Cohen's d = -0.282 (95% CI: -0.787, 0.222) in that ward. Both aspects declined as well in the other ward, but not significantly. Discussion: Results indicate that the implementation of the Safewards interventions according to the model in acute psychiatric care can reduce coercive measures. They also show the role of enabling factors as well as of obstacles for the implementation process.

Psychiatric nursing staffs' attitudes towards the use of containment methods in psychiatric inpatient care: An integrative review

One of the international objectives in psychiatric care is reducing the use of coercion. Containment methods are meant to keep patients safe, yet usually include coercion. Nurses play a key role in deciding whether or not containment should be used and, as such, their attitudes towards containment can significantly impact the extent to which these methods are applied. The aim of this integrative review was to identify, analyse, and synthesize the available research on psychiatric nursing staffs' attitudes towards containment methods in inpatient psychiatric care. An electronic search was conducted using the CINAHL, Scopus, and PsycINFO databases. In addition, the citations of identified studies were screened for relevant research. A total of 24 relevant papers published between 2002 and 2017 were selected for further analysis. These studies revealed variation in nursing staffs' attitudes towards the use of containment methods. The use of containment methods seems to be widely accepted and nurses reported rarely considering alternative measures. It appears that attitudes towards containment have continuously become more negative, although the change has not been very pronounced. The concept of attitude was only defined in two studies. Thus, future research should strive to clarify this concept, as a generally accepted definition for attitude within nursing research and the utilization of all dimensions of this concept are both essential to the nursing field. Currently, it would be important to focus on changing attitudes among psychiatric nursing staff to reduce the use of containment methods; this calls for more research on nursing staffs' attitudes.

Effects of Seclusion and Restraint in Adult Psychiatry: A Systematic Review

Background: Determining the clinical effects of coercion is a difficult challenge, raising ethical, legal, and methodological questions. Despite limited scientific evidence on effectiveness, coercive measures are frequently used, especially in psychiatry. This systematic review aims to search for effects of seclusion and restraint on psychiatric inpatients with wider inclusion of outcomes and study designs than former reviews. Methods: A systematic search was conducted following PRISMA guidelines, primarily through Pubmed, Embase, and CENTRAL. Interventional and prospective observational studies on effects of seclusion and restraint on psychiatric inpatients were included. Main search keywords were restraint, seclusion, psychiatry, effect, harm, efficiency, efficacy, effectiveness, and quality of life. Results: Thirty-five articles were included, out of 6,854 records. Studies on the effects of seclusion and restraint in adult psychiatry comprise a wide range of outcomes and designs. The identified literature provides some evidence that seclusion and restraint have deleterious physical or psychological consequences. Estimation of post-traumatic stress disorder incidence after intervention varies from 25% to 47% and, thus, is not negligible, especially for patients with past traumatic experiences. Subjective perception has high interindividual variability, mostly associated with negative emotions. Effectiveness and adverse effects of seclusion and restraint seem to be similar. Compared to other coercive measures (notably forced medication), seclusion seems to be better accepted, while restraint seems to be less tolerated, possibly because of the perception of seclusion as "non-invasive." Therapeutic interaction appears to have a positive influence on coercion perception. Conclusion: Heterogeneity of the included studies limited drawing clear conclusions, but the main results identified show negative effects of seclusion and restraint. These interventions should be used with caution and as a last resort. Patients' preferences should be taken into account when deciding to apply these measures. The therapeutic relationship could be a focus for improvement of effects and subjective perception of coercion. In terms of methodology, studying coercive measures remains difficult but, in the context of current research on coercion reduction, is needed to provide workable baseline data and potential targets for interventions. Well-conducted prospective cohort studies could be more feasible than randomized controlled trials for interventional studies.

What factors influence the decisions of mental health professionals to release service users from seclusion?

Mental health policy stipulates seclusion should only be used as an intervention of last resort and for the minimum possible duration. Current evidence details which service users are more likely to be secluded, why they are secluded, and what influences the decision to seclude them. However, very little is known about the decision to release service users from seclusion. An integrative review was undertaken to explore the decision-making processes of mental health professionals which guide the ending of seclusion. The review used a systematic approach to gather and thematically analyse evidence within a framework approach. The twelve articles identified generated one overriding theme, maintaining safety. In addition, several subthemes emerged including the process of risk assessing which was dependent upon interaction and control, mediated by factors external to the service user such as the attitude and experience of staff and the acuity of the environment. Service users were expected to demonstrate compliance with the process ultimately ending in release and reflection. Little evidence exists regarding factors influencing mental health professionals in decisions to release service users from seclusion. There is no evidence-based risk assessment tool, and service users are not routinely involved in the decision to release them. Support from experienced professionals is vital to ensure timely release from seclusion. Greater insight into influences upon decisions to discontinue episodes may support initiatives aimed at reducing durations and use of seclusion.

Modern forensic psychiatric hospital design: clinical, legal and structural aspects

Forensic psychiatric care must be provided within the least restrictive setting possible, whilst simultaneously maintaining appropriate levels of security. This presents particular challenges for the design of forensic psychiatric hospitals, which are required to provide both a therapeutic and a safe material environment, often for extended periods of treatment and rehabilitation. By taking into consideration variable trends in psychiatric service provision and myriad clinical, legal and ethical issues, interdisciplinary forensic facility design teams are at the very forefront in implementing the latest developments in medical architecture. Also, although there are significant differences in how forensic psychiatric services are organized around the world, the underlying clinical challenges and increasingly research-based treatment principles are similar worldwide; it is therefore becoming less acceptable to operate and develop national forensic services without reference to international standards. Accordingly, we here review the literature on what features of forensic psychiatric facilities best serve the needs of those patients who need to rely on them, and we present a systematic and widely applicable approach to the complex and costly challenge of modern forensic psychiatric hospital design.

Children's moral experiences of crisis management in a child mental health setting

The experiences of children related to conflict and crisis management in child mental health settings, especially those aged 12 and below, have been rarely studied. This study examined the moral experiences of children related to conflict and crisis management and the related use of restraint and seclusion in a child mental health setting. A 5-month focused ethnography using a participatory hermeneutic framework was conducted in a day hospital programme for children with severe disruptive disorders within a mental health institute. Children considered restraints and seclusion could help them feel safe in certain instances, for example if another child was being aggressive towards them or in exceptional cases to prevent self-injury. However, their own experiences of being restrained were predominantly negative, especially if not knowing the reason for their use, which they then found unfair. Some of the children emphasized the punitive nature of the use of restraints and seclusion, and most children disagreed with these practices when used as a punishment. Children's perspectives also highlighted the limits of the use of a uniform de-escalation approach by the staff to manage crises. Children considered discussing with the staff and developing a relationship with them as more helpful in case of a crisis then the use of a de-escalation approach or coercive strategies.

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

Restrictive practices continue to be used in mental health care despite increasing recognition of their harms and an international effort to reduce and ultimately eliminate their use. The aim of this qualitative study was to explore mental health nurses' views of the potential elimination of these practices. Nine focus groups were conducted with 44 mental health nurses across Australia, and the data analysed using thematic analysis. Overall, the nurses expressed significant fear about the potential elimination of restrictive practices and saw themselves as being blamed for both the use of these practices and the consequences should they be eliminated. Findings detail the conflicts facing staff in balancing the need for ward safety for everyone present while at the same time providing person-centred care. Nurses described the changing role of the mental health nurse in acute settings, being more focussed on risk assessment and medication while at the same time attempting to practise in trauma-informed person-centred ways. The impact on ward safety with increasing acuity of consumers plus the presence of forensic consumers and those affected by methamphetamine was emphasized. Change initiatives need to take into account nurses' deep concerns about the consequences of eliminating all forms of control measures in hospitals and respond to the symptoms and behaviours consumers present with and associated unpredictable and concerning behaviours. Attempts to eliminate restrictive practices should, therefore, be carefully considered and come with a clear articulation of alternatives to ensure the safety of consumers, visitors, and staff.

Implementing seclusion in forensic mental health care: A qualitative study of staff decision making

Forensic mental health nursing is a complex role and there is a tension between maintaining safety and promoting a therapeutic and patient centred approach. The use of restrictive practises such as seclusion is an issue. Two focus groups with registered nurses exploring attitudes and factors used in decision-making about seclusion use were analysed using interpretive description. Participants described the need to reduce the use of seclusion and the problematic nature of its utility as an ongoing intervention in contemporary mental healthcare. It was clear that there were complexities and competing variables involved in the decision-making process.

Long-Term Impact of a Tailored Seclusion Reduction Program: Evidence for Change?

International comparative studies show that Dutch seclusion rates are relatively high. Therefore, several programs to change this practice were developed and implemented. The purpose of this study was to examine the impact of a seclusion reduction program over a long time frame, from 2004 until 2013. Three phases could be identified; the phase of development and implementation of the program (2004-2007), the project phase (2008-2010) and the consolidation phase (2011-2013). Five inpatient wards of a mental health institute were monitored. Each ward had one or more seclusion rooms. Primary outcome were the number and the duration of seclusion incidents. Involuntary medication was monitored as well to rule out substitution of one coercive measure by another. Case mix correction for patient characteristics was done by a multi-level logistic regression analysis with patient characteristics as predictors and hours seclusion per admission hours as outcome. Seclusion use reduced significantly during the project phase, both in number (-73%) and duration (-80%) and was not substituted by the use of enforced medication. Patient compilation as analyzed by the multi- level regression seemed not to confound the findings. Findings show a slight increase in number and seclusion days over the last year of monitoring. Whether this should be interpreted as a continuous or temporary trend remains unclear and is subject for further investigation.

Effects of a Staff Training Intervention on Seclusion Rates on an Adult Inpatient Psychiatric Unit

The current article presents the effects of a 90-minute staff training intervention aimed at reducing inpatient psychiatric seclusion rates through strengthened staff commitment to seclusion alternatives and improved de-escalation skills. The intervention occurred at an 18-bed adult inpatient psychiatric unit whose seclusion rates in 2015 were seven times the national average. Although the project's primary outcome compared patient seclusion rates before and after the intervention, anonymous staff surveys measured several secondary outcomes. Seclusion rates were reduced from a 6-month pre-intervention average of 2.95 seclusion hours per 1,000 patient hours to a 6-month post-intervention average of 0.29 seclusion hours per 1,000 patient hours, a 90.2% reduction. Completed staff surveys showed significant staff knowledge gains, non-significant changes in staff attitudes about seclusion, non-significant changes in staff de-escalation skill confidence, and use of the new resource sheet by only 17% of staff. The key study implication is that time-limited, focused staff training interventions can have a measurable impact on reducing inpatient seclusion rates. [Journal of Psychosocial Nursing and Mental Health Services, 56(6), 23-30.].

Variables Associated With the Subjective Experience of Coercive Measures in Psychiatric Inpatients: A Systematic Review

OBJECTIVE

This systematic review presents evidence regarding factors that may influence the patient's subjective experience of an episode of mechanical restraint, seclusion, or forced administration of medication.

METHOD

Two authors searched CINAHL, PubMed, SCOPUS, Web of Science, and Psych-Info, considering published studies between 1 January 1992 and 1 February 2016. Based on the inclusion criteria and methodological quality, 34 studies were selected, reporting a total sample of 1,869 participants.

RESULTS

The results showed that the provision of information, contact and interaction with staff, and adequate communication with professionals are factors that influence the subjective experience of these measures. Humane treatment, respect, and staff support are also associated with a better experience, and debriefing is an important procedure/technique to reduce the emotional impact of these measures. Likewise, the quality of the working and physical environment and some individual and treatment variables were related to the experience of these measures. There are different results in relation to the most frequently associated experiences and, despite some data that indicate positive experiences, the evidence shows such experiences to be predominantly negative and frequently with adverse consequences. It seems that patients find forced medication and seclusion to be more tolerable than mechanical restraint and combined measures.

CONCLUSIONS

It appears that the role of the staff and the environmental conditions, which are potentially modifiable, affect the subjective experience of these measures. There was considerable heterogeneity among studies in terms of coercive measures experienced by participants and study designs.

Consumers' and their supporters' perspectives on barriers and strategies to reducing seclusion and restraint in mental health settings

Objective This paper examines the perspectives of consumers and their supporters regarding the use of seclusion and restraint in mental health settings. Methods Five focus groups for consumers and five focus groups for supporters were conducted in four Australian cities and in one rural location. The 66 participants were asked about strategies to reduce or eliminate the use of seclusion and restraint in mental health settings. Results All participants supported the reduction of the use of seclusion and restraint. Barriers to reducing these practices related to the environment, the effects of drug and alcohol issues, lack of a human rights focus and poor recognition of trauma, stigma and discrimination. Strategies for reducing or eliminating seclusion and restraint included workforce development, environmental and cultural changes. Conclusions Participants clearly identified that the status quo needs to change and conveyed urgency for action. Participants suggested that the involvement of supporters and a range of consumer roles are integral to reducing the use of seclusion and restraint. The findings support the current policy emphasis of working towards the elimination of these practices. What is known about the topic? Mental health policies across many jurisdictions support the reduction and elimination of restraint and seclusion. Evidence suggests those subjected to restraint and seclusion largely experience a range of harmful consequences. No studies focus on the views of supporters of consumers regarding the reduction and elimination of seclusion and restraint, whereas the views of consumers appear in a minority of international studies. What does this paper add? The research enabled an opportunity to hear from people who have been personally affected by and/or have lived experience of these coercive practices. Participants identified local reforms that can uphold the human rights of consumers. They suggested practices to increase accountability, peer support and family involvement, areas that have not been analysed in depth in any of the seclusion and restraint literature. What are the implications for practitioners? This paper will give healthcare services a deeper insight into how to reduce or eliminate restraint or seclusion from the perspective of those with lived experience.

Comparing Attitudes to Containment Measures of Patients, Health Care Professionals and Next of Kin

Background: In clinical psychiatric practice, health care professionals (HCP) must decide in exceptional circumstances after the weighing of interests, which, if any, containment measures including coercion are to be used. Here, the risk for patients, staff, and third parties, in addition to therapeutic considerations, factor into the decision. Patients' preference and the inclusion of relatives in these decisions are important; therefore, an understanding of how patients and next of kin (NOK) experience different coercive measures is crucial for clinical decision making. The aim of this study is to compare how patients, HCP, and NOK assess commonly used coercive measures. Methods: A sample of 435 patients, 372 HCP, and 230 NOK completed the Attitudes to Containment Measures Questionnaire (ACMQ). This standardized self-rating questionnaire assessed the degree of acceptance or rejection of 11 coercive measures. Results: In general, HCPs rated the coercive measures as more acceptable than did NOK and patients. The largest discrepancy in the ratings was found in regard to the application of coercive intramuscular injection of medication (effect size: 1.0 HCP vs. patients). However, the ratings by NOK were significantly closer to the patients' ratings compared to patients and HCP. The only exception was the acceptance of treatment in a closed acute psychiatric ward, which was deemed significantly more acceptable by NOK than by patients. Also, patients who had experienced coercive measures themselves more strongly refused other measures. Conclusion: Patients most firmly rejected intramuscular injections, and the authors agree that these should only be used with reservation considering a high threshold. This knowledge about the discrepancy of the ratings should therefore be incorporated into professional training of HCP.

"Treat me with respect". A systematic review and thematic analysis of psychiatric patients' reported perceptions of the situations associated with the process of coercion

WHAT IS KNOWN ON THE SUBJECT?: Psychiatric patients have generally negative experiences of being exposed to coercive measures. Existing research has generally not investigated coercion as a process; that is, it does not address issues that arise before, during and after exposure to coercion. A part of existing research within the area does not clarify and define the type of coercive measure(s) investigated. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Patients place great significance on the link between the positive and negative perceived impact of a coercive situation and the professionals' ability and willingness to interact and communicate respectfully. Psychiatric patients associate the use of seclusion, physical restraint/holding, mechanical restraint and forced medication with strong negative perceptions and wish to be treated with respect by professionals, rather than being subjected to the professionals' control. What patients perceive as moderating factors in regard to the use of coercive measures is currently under-researched. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Increased sensitivity to the patient's views of the situation at each point in the coercive process would help professionals to respond to the patients' individual needs. Professionals need to articulate concern and empathy towards patients and to improve communication skills before, during and after a coercive incident. Greater emphasis should be placed on de-escalation and the use of non-coercive strategies or coping skills before the initiation of coercive measures.

ABSTRACT

Introduction There is a lack of research into psychiatric patients' perceptions of coercion that discriminates between different types of coercive measures, while also investigating patients' perceptions of undergoing coercion as a process. This knowledge is required to improve our understanding and provide a foundation for improving clinical practice. Aims To review existing research literature in order to investigate adult psychiatric patients' reported perceptions of situations before, during and after specific and defined types of coercive measures, and to investigate what patients perceive as moderating factors, in regard to the use of these coercive measures. Method A systematic review and thematic analysis of 26 peer-reviewed studies was undertaken. Results The analysis identified six themes and additional subthemes, where "interactions with professionals" and "communication" were predominant themes across the timeline of coercion. Altogether, themes were associated with either "positive or negative patient-perceived impact." Implications for practice Increased sensitivity to patients' views of the situation at each point in the process is desirable in order to respond to the patients' individual needs. Professionals also need to articulate concern and empathy towards the patient and to improve communication skills before, during and after a coercive incident. Use of de-escalation and noncoercive strategies is required. Relevance statement Coercion within psychiatric/mental health care remains controversial, and repeated international calls have recommended a reduction of their use. This review indicates that greater attention to how patients perceive the use of coercive measures (before, during, and after incidents) needs to be considered in order to improve the evidence-based and clinical practice.

Nursing Staff Factors Contributing to Seclusion in Acute Mental Health Care - An Explorative Cohort Study

BACKGROUND

Seclusion is a controversial intervention. Efficacy with regard to aggressive behaviour has not been demonstrated, and seclusion is only justified for preventing safety hazards. Previous studies indicate that nursing staff factors may be predictors for seclusion, although methodological issues may have led to equivocal results.

OBJECTIVE

To perform a prospective cohort study to determine whether nursing staff characteristics are associated with seclusion of adult inpatients admitted to a closed psychiatric ward.

METHOD

We studied the association between nurses' demographics and incidence of seclusion during every shift. Data were collected during five months in 2013. Multiple logistic regression was used for analysis.

RESULTS

In univariable analysis, we found a non-significant association between seclusion and female gender, odds ratio (OR) = 5.27 (0.98-28.49) and a significant association between seclusion and nurses' large physical stature, OR = 0.21 (0.06-0.72). We found that physical stature is the most substantial factor, although not significant: OR_adjusted = 0.27 (0.07-1.04).

CONCLUSION

Nurses' gender may be a predictor for seclusion, but it seems to be mediated by the effect of physical stature. We used a rigorous, census-based, prospective design to collect data on a highly detailed level and found a large effect of physical stature of nurses on seclusion. We found nurses' physical stature to be the most substantial predictor for seclusion. These and other factors need to be explored in further research with larger sample size.

Seclusion and Psychiatric Intensive Care Evaluation Study (SPICES): combined qualitative and quantitative approaches to the uses and outcomes of coercive practices in mental health services

Background

Seclusion (the isolation of a patient in a locked room) and transfer to a psychiatric intensive care unit (PICU; a specialised higher-security ward with higher staffing levels) are two common methods for the management of disturbed patient behaviour within acute psychiatric hospitals. Some hospitals do not have seclusion rooms or easy access to an on-site PICU. It is not known how these differences affect patient management and outcomes.

Objectives

To (1) assess the factors associated with the use of seclusion and PICU care, (2) estimate the consequences of the use of these on subsequent violence and costs (study 1) and (3) describe differences in the management of disturbed patient behaviour related to differential availability (study 2).

Design

The electronic patient record system at one trust was used to compare outcomes for patients who were and were not subject to seclusion or a PICU, controlling for variables, including recent behaviours. A cost-effectiveness analysis was performed (study 1). Nursing staff at eight hospitals with differing access to seclusion and a PICU completed attitudinal measures, a video test on restraint-use timing and an interview about the escalation pathway for the management of disturbed behaviour at their hospital. Analyses examined how results differed by access to PICU and seclusion (study 2).

Participants

Patients on acute wards or PICUs in one NHS trust during the period 2008–13 (study 1) and nursing staff at eight randomly selected hospitals in England, with varying access to seclusion and to a PICU (study 2).

Main outcome measures

Aggression, violence and cost (study 1), and utilisation, speed of use and attitudes to the full range of containment methods (study 2).

Results

Patients subject to seclusion or held in a PICU were more likely than those who were not to be aggressive afterwards, and costs of care were higher, but this was probably because of selection bias. We could not derive satisfactory estimates of the causal effect of either intervention, but it appeared that it would be feasible to do so for seclusion based on an enriched sample of untreated controls (study 1). Hospitals without seclusion rooms used more rapid tranquillisation, nursing of the patient in a side room accompanied by staff and seclusion using an ordinary room (study 2). Staff at hospitals without seclusion rated it as less acceptable and were slower to initiate manual restraint. Hospitals without an on-site PICU used more seclusion, de-escalation and within-eyesight observation.

Limitations

Official record systems may be subject to recording biases and crucial variables may not be recorded (study 1). Interviews were complex, difficult, constrained by the need for standardisation and collected in small numbers at each hospital (study 2).

Conclusions

Closing seclusion rooms and/or restricting PICU access does not appear to reduce the overall levels of containment, as substitution of other methods occurs. Services considering expanding access to seclusion or to a PICU should do so with caution. More evaluative research using stronger designs is required.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Six years of national mental health seclusion data: the Australian experience

OBJECTIVES

Reducing or eliminating seclusion from mental health care settings has been a national priority for Australia since 2005. This paper describes Australia's national seclusion data collection, and summarises changes in seclusion rates in Australian public mental health services.

METHODS

Seclusion events per 1000 patient days were calculated from 2009-2010 to 2014-2015 utilising state and territory administrative data sources. Combined national data were used to calculate results for a number of service characteristics, such as target population and location of the service.

RESULTS

The rate of seclusion events decreased by 43% over the 6 years. Child and adolescent services reported consistently higher rates of seclusion, but a shorter duration of seclusion episodes, compared with other service types. There is high variation in seclusion rates between individual services (range 0.0-53.0 seclusion events per 1000 bed days in 2014-2015).

CONCLUSIONS

Seclusion event rates in Australia's specialised public acute mental health hospital services are declining. The use of existing administrative data was instrumental in establishing a national data source to facilitate the monitoring and reporting of progress of seclusion reduction strategies.

Study protocol for a cluster randomised controlled trial to assess the effectiveness of user-driven intervention to prevent aggressive events in psychiatric services

BACKGROUND

People admitted to psychiatric hospitals with a diagnosis of schizophrenia may display behavioural problems. These may require management approaches such as use of coercive practices, which impact the well-being of staff members, visiting families and friends, peers, as well as patients themselves. Studies have proposed that not only patients' conditions, but also treatment environment and ward culture may affect patients' behaviour. Seclusion and restraint could possibly be prevented with staff education about user-centred, more humane approaches. Staff education could also increase collaboration between patients, family members and staff, which may further positively affect treatment culture and lower the need for using coercive treatment methods.

METHODS

This is a single-blind, two-arm cluster randomised controlled trial involving 28 psychiatric hospital wards across Finland. Units will be randomised to receive either a staff educational programme delivered by the team of researchers, or standard care. The primary outcome is the incidence of use of patient seclusion rooms, assessed from the local/national health registers. Secondary outcomes include use of other coercive methods (limb restraint, forced injection, and physical restraint), service use, treatment satisfaction, general functioning among patients, and team climate and employee turn-over (nursing staff).

DISCUSSION

The study, designed in close collaboration with staff members, patients and their relatives, will provide evidence for a co-operative and user-centred educational intervention aiming to decrease the prevalence of coercive methods and service use in the units, increase the functional status of patients and improve team climate in the units. We have identified no similar trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02724748 . Registered on 25th of April 2016.

Secondary analysis of data can inform care delivery for Indigenous women in an acute mental health inpatient unit

There is a paucity of research exploring Indigenous women's experiences in acute mental health inpatient services in Australia. Even less is known of Indigenous women's experience of seclusion events, as published data are rarely disaggregated by both indigeneity and gender. This research used secondary analysis of pre-existing datasets to identify any quantifiable difference in recorded experience between Indigenous and non-Indigenous women, and between Indigenous women and Indigenous men in an acute mental health inpatient unit. Standard separation data of age, length of stay, legal status, and discharge diagnosis were analysed, as were seclusion register data of age, seclusion grounds, and number of seclusion events. Descriptive statistics were used to summarize the data, and where warranted, inferential statistical methods used SPSS software to apply analysis of variance/multivariate analysis of variance testing. The results showed evidence that secondary analysis of existing datasets can provide a rich source of information to describe the experience of target groups, and to guide service planning and delivery of individualized, culturally-secure mental health care at a local level. The results are discussed, service and policy development implications are explored, and suggestions for further research are offered.

Suicidal patients' experiences regarding their safety during psychiatric in-patient care: a systematic review of qualitative studies

Background

In-patient suicide prevention is a high priority in many countries, but its practice remains poorly understood. Patients in a suicidal crisis who receive psychiatric care can provide valuable insight into understanding and improving patient safety. The aim of this paper was therefore to summarize the qualitative literature regarding suicidal patients’ in-patient care experiences. The following question guided the review: How can we describe suicidal patients’ experiences regarding safety during psychiatric in-patient care?

Methods

Systematic searches were conducted in the MEDLINE, Academic Search Premier, CINAHL, SOCINDEX and PsycINFO databases, identifying 20 qualitative studies on suicidal patients and their psychiatric in-patient care experiences. These studies were systematically reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, synthesized via thematic analysis and subjected to quality appraisals.

Results

Patients described safety as “feeling safe”, and three components, i.e., connection, protection and control, were vital to their experiences of safety. Fulfilling these needs was essential to patients recovering from suicidal crises, feeling safe during encounters with health care professionals and feeling safe from suicidal impulses. Unmet needs for connection, protection and control left patients feeling unsafe and increased their suicidal behaviour.

Conclusion

Our review addresses the importance of adopting a wider perspective of patient safety than considering safety solely in technical and physical terms. Safety for the suicidal patient is highly dependent on patients’ perceptions of their psychological safety and the fulfilment of their needs. The three patient-identified factors mentioned above – connection, protection and control – should be considered an integral part of patient safety practices and should form the basis of future efforts to understand the safety of suicidal patients during psychiatric in-patient care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2023-8) contains supplementary material, which is available to authorized users.

Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial

Background

Acute psychiatric wards manage patients whose actions may threaten safety (conflict). Staff act to avert or minimise harm (containment). The Safewards model enabled the identification of ten interventions to reduce the frequency of both.

Objective

To test the efficacy of these interventions.

Design

A pragmatic cluster randomised controlled trial with psychiatric hospitals and wards as the units of randomisation. The main outcomes were rates of conflict and containment.

Participants

Staff and patients in 31 randomly chosen wards at 15 randomly chosen hospitals.

Results

For shifts with conflict or containment incidents, the experimental condition reduced the rate of conflict events by 15% (95% CI 5.6–23.7%) relative to the control intervention. The rate of containment events for the experimental intervention was reduced by 26.4% (95% CI 9.9–34.3%).

Conclusions

Simple interventions aiming to improve staff relationships with patients can reduce the frequency of conflict and containment.

Trial registration

IRSCTN38001825.

Consumers and Carer perspectives on poor practice and the use of seclusion and restraint in mental health settings: results from Australian focus groups

BACKGROUND

Seclusion and restraint are interventions currently permitted for use in mental health services to control or manage a person's behaviour. In Australia, serious concerns about the use of such seclusion and restraint have been raised at least since 1993. Consumers and their supporters have also expressed strong views about the harm of these practices. This paper presents the results of ten focus group discussions with people with lived experience of mental health issues and also carers, family members and support persons in relation to the use of seclusion and restraint.

METHODS

The 30 consumers and 36 supporters participating in the focus groups convened in four Australian cities and one regional centre discussed their understandings of the use of seclusion and restraint and its impact on the people involved. Participants also presented their observations about poor practice and what contributes to it as well as providing ideas and recommendations regarding strategies to reduce or eliminate seclusion and restraint. Focus group discussions were recorded and transcribed, then analysed using the NVivo 10 qualitative data analysis software with a general inductive approach used to analyse data. This analysis enabled consideration of the responses to key questions in the focus groups as well as the identification of emerging themes.

RESULTS

Six themes emerged from the analysis, these being: human rights, trauma, control, isolation, dehumanisation and 'othering', and anti-recovery. Examples of poor practice identified by focus groups included the use of excessive force, lack of empathy/paternalistic attitudes, lack of communication and interaction and a lack of alternative strategies to the use of seclusion and restraint. There was a confluence of factors identified by participants as contributing to poor practice, with the main factors being organisational culture, the physical environment, under-resourced mental health services and fear and stigma.

CONCLUSIONS

Focus group participants in the main viewed seclusion and restraint practices in mental health settings as unnecessarily overused, exacerbating problems for individuals, carers, staff and the broader system of care. This study highlights that lived experience of both consumers and their supporters can make an important contribution to mental health services and its ongoing reform.

Understanding Mental Health Service User Experiences of Restraint Through Debriefing: A Qualitative Analysis

OBJECTIVE

To examine debriefing data to understand experiences before, during, and after a restraint (seclusion, chemical, and physical) event from the perspective of inpatients at a large urban mental health and addiction hospital.

METHOD

Audits were conducted on a purposeful sample of inpatient charts containing post-restraint event inpatient debrief forms (n = 55). Qualitative data from the forms were analyzed thematically.

RESULTS

Loss of autonomy and related anger, conflict with staff and other inpatients, and unmet needs were the most common factors precipitating restraint events. Inpatients often reported that increased communication with staff could have prevented restraint. Inpatients described having had various negative emotional states and responses during restraint events, including fear and rejection. Post-restraint, inpatients often desired to leave the unit for fresh air or to engage in leisure activities.

CONCLUSIONS

To our knowledge, our study is the first to use debriefing form data to explore mental health inpatients' experiences of restraint. Inpatients view restraint negatively and do not experience it as a therapeutic intervention. Debriefing, guided by a form, is useful for understanding the inpatient's experience of restraint, and should be used to re-establish the therapeutic relationship and to inform plans of care. In addition, individual and collective inpatient perspectives should inform alternatives to restraint.

Seclusion experienced by mental health professionals

Seclusion in psychiatric inpatient care means confining service users in a locked room. Service users and staff seem to have different opinions on the usefulness of seclusion. This is possibly the first time when two mental health nurses went voluntarily into seclusion and reported their experiences. The nurses felt that the seclusion room was inhumane and proposed improvements to seclusion in general and to the seclusion facilities in particular. Seclusion in psychiatric hospital care refers to isolating a service user from other service users and staff, most often in a locked and unfurnished room. Service users' experiences of seclusion are mostly negative, and although some have seen a rationale for its use, mental health nurses should be encouraged to evaluate current seclusion practices from the service user's perspective. In this small-scale experiment, two mental health nurses were voluntarily secluded for 24 h. The aim was to explore the experience of being secluded, to understand and evaluate the impact of seclusion in greater detail, and to encourage discussion on one of the controversies in mental health nursing. To the best of our knowledge, this is the first attempt to evaluate the impact of seclusion based on mental health nurses' firsthand experiences. The nurses received usual seclusion treatment and described their experiences of this every 6 h. Based on the nurses' experiences, seclusion, even in voluntary, safe and planned circumstances, may increase anxiety and frustration. Seclusion was viewed negatively and the physical environment was considered inhumane. The nurses offered some practical suggestions for updating seclusion practices and re-designing seclusion facilities. Mental health nurses, who frequently decide on and invariably implement seclusion, are key to improving seclusion practices.