Mental health nursing practice in acute psychiatric close-observation areas

Everyday ordinariness, neglected but important for mental health nurses' therapeutic relationships: An initial exploration for applying Daniel Kahneman's two systems of thinking

Mental health nurses undertake difficult and complex roles. Therapeutic relationships and engagement between mental health nurses and people experiencing severe mental ill-health provide the core purpose and rationale for such mental health care. These relationships are influenced by factors outside of frontline mental health nurses control. They are difficult to define or describe with clarity, have limited 'quantitative' evidence of effectiveness and are frequently not experienced as therapeutic. This paper presents some initial ideas regarding 'everyday ordinariness' using psychologist Daniel Kahneman's two systems of thinking as a focus for understanding and potentially improving mental health nurse practice, and therapeutic relationships and engagement.

An Integrative Review on Psychiatric Intensive Care

Psychiatric intensive care units (PICUs) provide care and treatment when psychiatric symptoms and behaviors exceed general inpatient resources. This integrative review aimed to synthesize PICU research published over the past 5 years. A comprehensive search in MEDLINE, PsycINFO, PubMed and Scopus identified 47 recent articles on PICU care delivery, populations, environments, and models. Research continues describing patient demographics, and high rates of challenging behaviors, self-harm, and aggression continue being reported. Research on relatives was minimal. Patients describe restrictive practices incongruent with recovery philosophies, including controlling approaches and sensory deprivation. Some initiatives promote greater patient autonomy and responsibility in shaping recovery, yet full emancipatory integration remains limited within PICU environments. Multidisciplinary collaboration is needed to holistically advance patient-centered, equitable, and integrative PICU care. This review reveals the complex tensions between clinical risk management and emancipatory values in contemporary PICU settings. Ongoing reporting of controlling practices counters the recovery movement progressing in wider mental healthcare contexts. However, care innovations centered on patient empowerment and humane environments provide hope for continued evolution toward more liberation-focused PICU approaches that uphold both patient and provider perspectives.

Caring Knowledge as a Strategy to Mitigate Violence against Nurses: A Discussion Paper

Violence against nurses is a disturbing trend in healthcare that has reached epidemic proportions globally. These violent incidents can result in physical and psychological injury, exacerbating already elevated levels of stress and burnout among nurses, further contributing to absenteeism, turnover, and intent to leave the profession. To ensure the physical and mental well-being of nurses and patients, attention to the development of strategies to reduce violence against nurses must be a priority. Caring knowledge-rooted in the philosophy of care-is a potential strategy for mitigating violence against nurses in healthcare settings. We present what caring knowledge is, analyze its barriers to implementation at the health system and education levels and explore potential solutions to navigate those barriers. We conclude how the application of models of caring knowledge to the nurse-patient relationship has the potential to generate improved patient safety and increased satisfaction for both nurses and patients.

Nurses' and Patients' Perceptions about Psychiatric Intensive Care-An Integrative Literature Review

This integrative literature review describes nurses's and patients' perceptions of care in psychiatric intensive care units (PICU). The database search was conducted in April 2020. PRISMA checklist and Mixed Method Appraisal Tool guided the identification and evaluation of the studies (n = 21). Data was analyzed with qualitative content analysis. Nurses perceived PICU as a challenging work environment where their primary task was to ensure the unit's safety. Patients views on their treatment varied from positive to negative. Patients wished to have more privacy and supportive interaction. Findings can be used as a basis in developing care practices and staff's further education in PICUs.

Invisible experts: a systematic review & thematic synthesis of informal carer experiences of inpatient mental health care

BACKGROUND

The negative impact of caregiving on carers' physical and psychological wellbeing is well documented. Carers of mental health inpatients have particularly negative experiences and largely report being dissatisfied with how they and their loved one are treated during inpatient care. It remains unclear why, despite policies intended to improve inpatient experiences. A comprehensive review of carers' inpatient experiences is needed to understand carer needs. As such, we aimed to conduct a systematic review and thematic synthesis of carer experiences of inpatient mental health care.

METHODS

We searched MEDLINE, PsycINFO, Embase and CINAHL for qualitative studies examining carer experiences of mental health inpatient care. Searches were supplemented by reference list screening and forward citation tracking of included studies. Results were synthesised using thematic synthesis. Our protocol was registered on PROSPERO (CRD42020197904) and our review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

FINDINGS

Twelve studies were included from 6 countries. Four themes were identified: the emotional journey of inpatient care; invisible experts; carer concerns about quality of care for their loved one; and relationships and partnership between carers, service users and staff.

INTERPRETATION

Greater attention should be paid to ensure carers are well-supported, well-informed, and included in care. More emphasis must be placed on fostering positive relationships between carers, service users and staff and in facilitating continuity of care across inpatient and community services to provide carers with a sense of security and predictability. Further research is needed to explore differences in experiences based on carer and service user characteristics and global context, alongside co-production with carers to develop and evaluate future guidelines and policies.

Patients' Health & Well-Being in Inpatient Mental Health-Care Facilities: A Systematic Review

Background: Previous research indicates that the physical environment of healthcare facilities plays an important role in the health, well-being, and recovery outcomes of patients. However, prior works on mental healthcare facilities have incorporated physical environment effects from general healthcare settings and patient groups, which cannot be readily transferred to mental healthcare settings or its patients. There appears to be a specific need for evidence synthesis of physical environmental effects in mental healthcare settings by psychopathology. Purpose: This review evaluates the state (in terms of extent, nature and quality) of the current empirical evidence of physical environmental on mental health, well-being, and recovery outcomes in mental healthcare inpatients by psychopathology. Method: A systematic review (PRISMA guidelines) was performed of studies published in English, German, Dutch, Swedish, and Spanish, of all available years until September 2020, searched in Cochrane, Ovid Index, PsycINFO, PubMed, and Web of Science and identified through extensive hand-picking. Inclusion criteria were: Adult patients being treated for mental ill-health (common mental health and mood disorders, Cochrane frame); inpatient mental health care facilities; specifications of the physical and socio-physical environment (e.g., design features, ambient conditions, privacy); all types of empirical study designs. Quality assessment and data synthesis were undertaken. Results: The search retrieved 1,068 titles of which 26 met the inclusion criteria. Findings suggest that there is only indicative evidence of the impact of the physical healthcare environment on patients' mental health, well-being, and recovery outcomes. There is significant lack of pathology-specific evidence. Methodological shortcomings and empirical scarcity account for the poor evidence. Conclusion: This review highlights the need for more research using advanced study designs.

International research into 22 years of use of chemical restraint: An evidence overview

BACKGROUND

Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non-consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice.

AIMS

To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995.

METHODS

This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures.

RESULTS

This review identified 311 relevant primary studies (21 RCTs; 46 non-controlled experimental or prospective observational studies; 77 cross-sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross-country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%).

DISCUSSION

A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non-consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non-chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research.

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.

Patient safety in inpatient mental health settings: a systematic review

OBJECTIVES

Patients in inpatient mental health settings face similar risks (eg, medication errors) to those in other areas of healthcare. In addition, some unsafe behaviours associated with serious mental health problems (eg, self-harm), and the measures taken to address these (eg, restraint), may result in further risks to patient safety. The objective of this review is to identify and synthesise the literature on patient safety within inpatient mental health settings using robust systematic methodology.

DESIGN

Systematic review and meta-synthesis. Embase, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium, MEDLINE, PsycINFO and Web of Science were systematically searched from 1999 to 2019. Search terms were related to 'mental health', 'patient safety', 'inpatient setting' and 'research'. Study quality was assessed using the Hawker checklist. Data were extracted and grouped based on study focus and outcome. Safety incidents were meta-analysed where possible using a random-effects model.

RESULTS

Of the 57 637 article titles and abstracts, 364 met inclusion criteria. Included publications came from 31 countries and included data from over 150 000 participants. Study quality varied and statistical heterogeneity was high. Ten research categories were identified: interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorised leave, clinical decision making, falls and infection prevention and control.

CONCLUSIONS

Patient safety in inpatient mental health settings is under-researched in comparison to other non-mental health inpatient settings. Findings demonstrate that inpatient mental health settings pose unique challenges for patient safety, which require investment in research, policy development, and translation into clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42016034057.

Sound practice: Exploring the benefits of establishing a music group on an acute mental health inpatient unit

There is evidence supporting the use of formal music therapy in the treatment of mental health consumers. Despite this, it appears to be an intervention which has not been routinely offered to consumers in Australian acute mental health inpatient units, possibly due to the lack of trained music therapists (or inadequate funding to employ them), as well as the challenges posed by the acuity of presentations and the short duration of admissions. Less formal therapeutic music activities may benefit consumers within these settings. This article describes how a music group activity facilitated by clinical staff with no music therapy qualifications was established. The first phase of this evaluation is then described using a descriptive qualitative method. We undertook a series of consumer and staff focus groups to explore the impact of a music group activity on an acute mental health inpatient unit. Five themes emerged from the transcripts of the focus groups' discussions, effects on mood, relationships and engagement, social connectedness and inclusion, the ward atmosphere and noise/agitation. Positive effects were shown across these areas, suggesting that the music group activity we established was beneficial for consumers and staff, and enhanced the ward atmosphere.

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.

Assistants in nursing working with mental health consumers in the emergency department

Nursing students, regardless of setting, require skills in working with people with mental health issues. One way to provide students with learning opportunities within the context of limited undergraduate mental health content and lack of mental health placements is through employment as assistants in nursing (AIN). The purpose of the study was to investigate the use of AINs employed in an emergency department in South Australia to supervise (continuous observation) mental health consumers on inpatient treatment orders. Twenty-four participants took part in the study, with AINs (n = 8, all studying in an undergraduate nursing programme), nurse managers (n = 5), and nurses (n = 11) participating in semi-structured interviews. Data were analysed using thematic analysis. Themes focused on (i) the AIN role, their practice, boundaries or restrictions of their role, and the image consumers have of AINs; (ii) learning through experience, where the AIN role was a practical opportunity to learn and apply knowledge obtained through university studies; and (iii) support, which focused on how AINs worked with nursing staff as part of the healthcare team. Overall, participants believed that AINs played an important role in the ED in supervising consumers on involuntary mental health treatment orders, where their unique role was seen to facilitate more positive consumer experiences. The AIN role is one way for nursing students to develop skills in working with people with mental health issues.

De-escalation techniques for managing non-psychosis induced aggression in adults

BACKGROUND

Aggression occurs frequently within health and social care settings. It can result in injury to patients and staff and can adversely affect staff performance and well-being. De-escalation is a widely used and recommended intervention for managing aggression, but the efficacy of the intervention as a whole and the specific techniques that comprise it are unclear.

OBJECTIVES

To assess the effects of de-escalation techniques for managing non-psychosis-induced aggression in adults in care settings, in both staff and service users.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and 14 other databases in September 2017, plus three trials registers in October 2017. We also checked references, and contacted study authors and authorities in the field to identify additional published and unpublished studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing de-escalation techniques with standard practice or alternative techniques for managing aggressive behaviour in adult care settings. We excluded studies in which participants had psychosis.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

This review includes just one cluster-randomised study of 306 older people with dementia and an average age of 86 years, conducted across 16 nursing homes in France. The study did not measure any of our primary or secondary outcomes but did measure behavioural change using three measurement scales: the Cohen-Mansfield Agitation Inventory (CMAI; 29-item scale), the Neuropsychiatric Inventory (NPI; 12-item scale), and the Observation Scale (OS; 25-item scale). For the CMAI, the study reports a Global score (29 items rated on a seven-point scale (1 = never occurs to 7 = occurs several times an hour) and summed to give a total score ranging from 29 to 203) and mean scores (evaluable items (rated on the same 7-point scale) divided by the theoretical total number of items) for the following four domains: Physically Non-Aggressive Behaviour, such as pacing (13 items); Verbally Non-Aggressive Behaviour, such as repetition (four items); Physically Aggressive Behaviour, such as hitting (nine items); and Verbally Aggressive Behaviour, such as swearing (three items). Four of the five CMAI scales improved in the intervention group (Global: change mean difference (MD) -5.69 points, 95% confidence interval (CI) -9.59 to -1.79; Physically Non-Aggressive: change MD -0.32 points, 95% CI -0.49 to -0.15; Verbally Non-Aggressive: change MD -0.44 points, 95% CI -0.69 to -0.19; and Verbally Aggressive: change MD -0.16 points, 95% CI -0.31 to -0.01). There was no difference in change scores on the Physically Aggressive scale (MD -0.08 points, 95% CI -0.37 to 0.21). Using GRADE guidelines, we rated the quality of this evidence as very low due to high risk of bias and indirectness of the outcome measures. There were no differences in NPI or OS change scores between groups by the end of the study.We also identified one ongoing study.

AUTHORS' CONCLUSIONS

The limited evidence means that uncertainty remains around the effectiveness of de-escalation and the relative efficacy of different techniques. High-quality research on the effectiveness of this intervention is therefore urgently needed.

Associations between psychiatric symptoms and seclusion use: Clinical implications for care planning

Findings from an increasing number of studies suggest that incorporating systematic short-term risk assessments in treatment planning could lead to safer practice on psychiatric admissions wards. The aim of the present study was to investigate the associations between the scores of three structured observation tools - the Kennedy Axis V (K-Axis-V), the Brief Psychiatric Rating Scale (BPRS), and the Social Dysfunction and Aggression Scale (SDAS) - and seclusion. In total, 1840 weekly risk assessments with these observation scales were collected over 2342 admission weeks. These assessment scores related to 370 acutely-admitted psychiatric patients and were subjected to a multilevel analysis. It was found that several dynamic and static factors were related to seclusion. Dynamic factors included violent behaviour, current substance abuse, suspiciousness, and negativism. Static factors included ethnicity and having been diagnosed with a substance abuse disorder. The findings suggest that the incorporation of the Kennedy-Axis V, the BPRS, and the SDAS into standard practice might be helpful in identifying patients at high risk of seclusion, and could be supportive to treatment planning and clinical decision-making in the prevention of seclusion use in acute psychiatric settings.

Is restraint a 'necessary evil' in mental health care? Mental health inpatients' and staff members' experience of physical restraint

Restraint in mental health care has negative consequences, and guidelines/policies calling for its reduction have emerged internationally. However, there is tension between reducing restraint and maintaining safety. In order to reduce restraint, it is important to gain an understanding of the experience for all involved. The aim of the present study was to improve understanding of the experience of restraint for patients and staff with direct experience and witnesses. Interviews were conducted with 13 patients and 22 staff members from one UK National Health Service trust. The overarching theme, 'is restraint a necessary evil?', contained subthemes fitting into two ideas represented in the quote: 'it never is very nice but…it's a necessary evil'. It 'never is very nice' was demonstrated by the predominantly negative emotional and relational outcomes reported (distress, fear, dehumanizing, negative impact on staff/patient relationships, decreased job satisfaction). However, a common theme from both staff and patients was that, while restraint is 'never very nice', it is a 'necessary evil' when used as a last resort due to safety concerns. Mental health-care providers are under political pressure from national governments to reduce restraint, which is important in terms of reducing its negative outcomes for patients and staff; however, more research is needed into alternatives to restraint, while addressing the safety concerns of all parties. We need to ensure that by reducing or eliminating restraint, mental health wards neither become, nor feel, unsafe to patients or staff.

Roles of Psychiatry Nurses Within a Therapeutic Environment of Psychiatry Clinics in Turkey

OBJECT

The object of this study is to determine the roles of psychiatry nurses within the therapeutic environment of psychiatry clinics in Turkey.

METHODS

This study was performed in a cross-sectional and descriptive design in 195 institutes comprising psychiatry clinics in Turkey.

RESULTS

When the responsibilities of nurses for clinical activities were asked, the following answers were obtained: playing with patients or painting at a rate of 54,4%. It was determined that in the majority of psychiatry clinics, there were educational activities which were conducted by nurses.

CONCLUSION

The researchers propose that the increase in the roles and responsibilities of nurses in such activities be supported.

A retrospective study describing the characteristics of one Mental Health Trust's admissions under sections 47 and 48 of the Mental Health Act 1983

Sections 47 and 48 of the Mental Health Act 1983 allow prisoners to be transferred from prison to an appropriate health-care setting in order to be treated. There is an awareness that delays exist when transferring prisoners to hospital. However, literature regarding the delay in returning these patients from hospital is limited. The admissions from prison to a Psychiatric Intensive Care Unit (PICU) in South West London were compared to non-offenders on the PICU in order to compare the average length of stay for both groups and the time taken for the discharge from PICU once felt clinically appropriate. The study also compared demographic profiles, reason for admissions, psychiatric diagnosis and index offences. Over six years, there were 18 admissions from prison to a PICU. The control group comprised 37 non-offenders admitted to the same PICU. On average the prison group took longer to be deemed clinically ready for discharge and, even once clinically ready, then took longer to be discharged. The average length of stay in PICU was 77.83 days for prisoners, and 16.46 days for non-offenders. All 55 admissions were between 1 January 2008 and 31 December 2014. The offender pathway and the difference in the length of stay between prisoners and non-offenders in a PICU warrants further exploration. Possible recommendations to reduce the length of stay of prisoners include improved information sharing between prisons and hospital, and clearer guidelines regarding the level of security required.

Implementing family involvement in the treatment of patients with psychosis: a systematic review of facilitating and hindering factors

OBJECTIVE

To synthesise the evidence on implementing family involvement in the treatment of patients with psychosis with a focus on barriers, problems and facilitating factors.

DESIGN

Systematic review of studies evaluating the involvement of families in tripartite communication between health professionals, 'families' (or other unpaid carers) and adult patients, in a single-family context. A theoretical thematic analysis approach and thematic synthesis were used.

DATA SOURCES

A systematic electronic search was carried out in seven databases, using database-specific search strategies and controlled vocabulary. A secondary manual search of grey literature was performed as well as using forwards and backwards snowballing techniques.

RESULTS

A total of 43 studies were included. The majority featured qualitative data (n=42), focused solely on staff perspectives (n=32) and were carried out in the UK (n=23). Facilitating the training and ongoing supervision needs of staff are necessary but not sufficient conditions for a consistent involvement of families. Organisational cultures and paradigms can work to limit family involvement, and effective implementation appears to operate via a whole team coordinated effort at every level of the organisation, supported by strong leadership. Reservations about family involvement regarding power relations, fear of negative outcomes and the need for an exclusive patient-professional relationship may be explored and addressed through mutually trusting relationships.

CONCLUSIONS

Implementing family involvement carries additional challenges beyond those generally associated with translating research to practice. Implementation may require a cultural and organisational shift towards working with families. Family work can only be implemented if this is considered a shared goal of all members of a clinical team and/or mental health service, including the leaders of the organisation. This may imply a change in the ethos and practices of clinical teams, as well as the establishment of working routines that facilitate family involvement approaches.

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

This review explores patient and staff perceptions and improvement suggestions regarding seclusion in psychiatric inpatient settings. After an extensive literature search, 39 empirical papers were included in the review. According to the literature, patients perceived seclusion to be a distinct negative incident. Staff thought seclusion had a therapeutic effect and believed that units could not operate effectively without seclusion, but regretted that the situation was not resolved differently. Staff and patients had suggestions to improve the seclusion experience. Common themes in relation to the implications for practice are the need for better communication and more contact between patients and staff before, during and after the seclusion event.

Early detection of risk factors for seclusion and restraint: a prospective study

AIM

The study aims to examine the predictive power of static and dynamic risk factors assessed at admission to an acute psychiatric ward and to develop a prediction model evaluating the risk of seclusion and restraint.

METHODS

Over 20 months, data on demographic and clinical characteristics, psychosocial functioning, level of insight, uncooperativeness, and use of coercive measures were collected prospectively on 520 patients at admission. Logistic regression analysis was used to develop a prediction model. The magnitude of the predictive power of this model was estimated using receiver operating characteristic analysis.

RESULTS

The prediction model contained one static predictor (involuntary commitment) and two dynamic predictors (psychological impairment and uncooperativeness), with a high predictive power (receiver operating characteristic area under the curve = 0.83). The final risk model classified 72% of the patients correctly, with a higher sensitivity rate (80%) than specificity rate (71%).

CONCLUSION

Early assessment of patients' psychological impairment and uncooperativeness can help clinicians to recognize patients at risk for coercive measures and approach them on time with preventive and less restrictive interventions. Although this simple, highly predictive model accurately predicts the risk of seclusion or restraint, further validation studies are needed before it can be adopted into routine clinical practice.

The practice of seclusion and time-out on English acute psychiatric wards: the City-128 Study

BACKGROUND

Seclusion is widely used internationally to manage disturbed behavior by psychiatric patients, although many countries are seeking to reduce or eliminate this practice. Time-out has been little described and almost completely unstudied.

AIM AND METHOD

To assess the relationship of seclusion and time-out to conflict behaviors, the use of containment methods, service environment, physical environment, patient routines, staff characteristics, and staff group variables. Data from a multivariate cross-sectional study of 136 acute psychiatric wards in England were used to conduct this analysis.

RESULTS

Seclusion is used infrequently on English acute psychiatric wards (0.05 incidents per day), whereas time-out use was more frequent (0.31 incidents per day). Usage of seclusion was strongly associated with the availability of a seclusion room. Seclusion was associated with aggression, alcohol use, absconding, and medication refusal, whereas time-out was associated with these and other more minor conflict behaviors. Both were associated with the giving of "as required" medication, coerced intramuscular medication, and manual restraint. Relationships with exit security for the ward were also found.

CONCLUSIONS

Given its low usage rate, the scope for seclusion reduction in English acute psychiatry may be small. Seclusion reduction initiatives need to take a wider range of factors into account. Some substitution of seclusion with time-out may be possible, but a rigorous trial is required to establish this. The safety of intoxicated patients in seclusion requires more attention.

"On the spot" interventions by mental health nurses in inpatient psychiatric wards in Greece

The objective of this research was to explore the "on-the spot" clinical interventions mental health nurses make in critical incidents on inpatient psychiatric wards. Mental health nurses play a key role in the management of psychiatric critical incidents. Nurses' autonomy, decision-making, and training in clinical interventions are important issues in psychiatric nursing practice. A descriptive study was conducted among mental health nurses working on inpatient wards of three major psychiatric hospitals in the greater Athens area, using semi-structured interviews. Nurses' personal views also were documented. Semi-structured interviews were conducted with 103 mental health nurses, who were encouraged to make personal remarks. The results of this study show that in the majority of critical incidents, the nurses were found to be in contact with the psychiatrist on call; physical restraints were used frequently in violent episodes; reassurance and support were common interventions; the majority of nurses would have preferred not to intervene with critical incidents; and nurses expressed a need for skills training and higher autonomy. The nurses implemented a specific number of interventions in confronting the various types of crises. The need for specialized training was noticed and problems like accountability, autonomy, and medication administration, were considered crucial by the mental heath nurses.

Mental health nurses establishing psychosocial interventions within acute inpatient settings

Acute inpatient units provide care for the most acutely unwell people experiencing a mental illness. As a result, the focus for care is on the containment of difficult behaviour and the management of those considered to be 'at high risk' of harm. Subsequently, recovery-based philosophies are being eroded, and psychosocial interventions are not being provided. Despite the pivotal role that mental health nurses play in the treatment process in the acute inpatient setting, a review of the literature indicates that mental health nursing practice is too custodial, and essentially operates within an observational framework without actively providing psychosocial interventions. This paper will discuss the problems with mental health nursing practice in acute inpatient units highlighted in the current literature. It will then put forward the argument for routine use of psychosocial interventions as a means of addressing some of these problems.

Learning from experience: Using action research to discover consumer needs in post-seclusion debriefing

Approximately 16% of consumers are secluded during an inpatient admission. Despite the harmful psychological consequences resulting from the use of physical force, restraint, control, and temporary sequestration of therapeutic communication, there is little evidence of nursing practices to support consumers who are secluded. This paper will outline the findings from an action research project examining post-seclusion debriefing practice. A series of focus groups was undertaken with mental health nurses (MHN) and consumer consultants (CC) to investigate current practice, identify consumer/clinician preferences, and scope future practice possibilities. The findings suggest that CC need assistance in dealing with the negative feelings evoked by seclusion. MHN use a range of approaches for debriefing; however, these sometimes do not meet consumer preferences. MHN focus on explaining why seclusion happened and how to avoid it. While mitigation is a critical issue, CC want more emotional support from debriefing. MHN saw the possibility of using the debriefing to support consumers' transit from seclusion to high-dependency status and then to low-dependency status. Opinions raised regarding the potential for CC to have a role in debriefing were divided. The findings will be used to inform the development of a consumer debriefing training program for MHN and CC.

'I'm not an outsider, I'm his mother!' A phenomenological enquiry into carer experiences of exclusion from acute psychiatric settings

Contemporary standards and policies advocate carer involvement in planning, implementing, and evaluating mental health services. Critics have questioned why such standards and policies fail to move from rhetoric to reality, this particularly being applicable to carer involvement within acute psychiatric settings. As there is only limited UK research on this topic, this interpretive phenomenological study was undertaken to explore the perceived level of involvement from the perspective of carers of service users who were admitted to acute inpatient settings within the previous 2 years. Interviews were conducted with four individuals who cared for a loved one with a mental illness. The interview analysis was influenced by Van Manen, whose interpretive approach seeks to generate a deeper understanding of the phenomenon under study. Four main themes emerged: powerlessness, feeling isolated, needing to be recognized and valued, and a desire for partnership. The findings reflect the views expressed by carers in other studies, identifying that while carers seek to work in partnership with health-care professionals, at a clinical level they often feel excluded. The study concludes by discussing ways of improving and promoting carer involvement and advocating a partnership in care approach within acute psychiatry.

Pro re nata medication for psychiatric inpatients: time to act

Pro re nata (PRN; 'as needed') medication is an archetypal mainstay for managing acute psychiatric inpatient symptoms and behaviours. Psychiatric and mental health nursing practices have circumnavigated the development of a uniform medical-ethical standard for the administration of PRN psychotropic medication. This paper examines the evidence for administration of PRN psychotropic medications and, in the context of evidence-based best practice, current mental health policy and professional ethics, proposes a standardized Australian PRN administration protocol. The procedures and circumstances leading to a nurse administering psychotropic PRN medication are divided into five simple steps, namely (i) medical prescription; (ii) nurse evaluation of patient indications for an intervention; (iii) nurse consideration of therapeutic options; (iv) obtaining patient informed consent; and (v) documentation of outcomes of PRN administration. The literature associated with each step is reviewed, along with national and international professional ethics, guidelines and patient rights documents pertaining to the care of mental health patients. Recommendations for best-practise care are discussed for each step. There is a lacuna of published evidence supporting the use of PRN medications in psychiatric inpatients. Yet there is published evidence that PRN medications are associated with increased risks of morbidity, inappropriate use, may result in above-recommended dosages or polypharmacy, and complicate the assessment of efficacy of regular scheduled medicines. Alternative non-pharmacological treatment options to PRN medication are effective and associated with fewer side-effects. There are no national explicit standards, operational criteria or quality assurance for the use of PRN medication in inpatient psychiatric units. Contemporary PRN practices are largely unregulated and driven by essentially anecdotal evidence, leaving the clinicians and the service open to claims of poor accountability and misuse (intentional and unintentional) of psychotropic medications. Development of best practice guidelines for the use of PRN administration is essential.

Psychiatric intensive care units: a literature review

BACKGROUND

Psychiatric Intensive Care Units (PICU) have been part of most inpatient psychiatric services for some time, although information about their functioning and outcome has not previously been collated.

AIM

To conduct a systematic literature review to assess the current state of knowledge about such services.

METHOD

A search of electronic databases was undertaken, followed by obtaining additional references from items obtained.

RESULTS

Over 50 papers in English containing some empirical data were identified. Most studies were retrospective. Typical PICU patients are male, younger, single, unemployed, suffering from schizophrenia or mania, from a Black Caribbean or African background, legally detained, with a forensic history. The most common reason for admission is for aggression management, and most patients stay a week or less. Evidence of the efficacy of PICU care is very poor.

CONCLUSIONS

Most research so far has been small scale, and more substantial work using better methodologies is clearly required.

The recovery alliance theory of mental health nursing

The recovery alliance theory (RAT) is a mid-range theory of mental health nursing based on humanistic philosophy. The conception of the RAT was the outcome of collaboration among service users, practising mental health nurses, educationalists and managers and was developed in the context of a number of political and social changes as well as changes in the mental health field. The theory is composed of six constructs: humanistic philosophy, recovery, partnership relation, strengths focus, empowerment and common humanity. The derivation of three concepts from these constructs, namely coping, self-responsibility/control and working alliance, forms the basis for the translation of the constructs into a system of mental health nursing practice [Partnership in Coping system (PinC)]. The constructs underpinning the RAT were clearly demonstrated in a preliminary trial of the PinC system.

Exploration of therapeutic interventions that accompany the administration of p.r.n. ('as required') psychotropic medication within acute mental health settings: a retrospective study

Within acute mental health settings, pro re nata (p.r.n.) 'as required' medication is a widely used adjunct to regular treatment plans, and is administered at the discretion of a registered nurse. However, there is concern that some orders may benefit staff more than patients by providing a 'quick fix' to compensate for inadequate therapeutic programmes. Previous authors assert that p.r.n. medication administration should not be the first line of action, but should be used when other less invasive interventions such as de-escalation, talking, or separation from the group are unsuccessful. This project explored the occurrence of p.r.n. medication administration and the type of alternative therapeutic interventions that are documented as accompanying its administration. A retrospective 1-month chart audit was undertaken for a cohort of inpatients in a 20-bed mental health facility attached to a regional hospital in New South Wales, Australia. Forty-seven patients (73.4%) received p.r.n. medication at least once, with a total of 309 doses of p.r.n. medication administered during this time. There were wide variations in the documented rationales, and for nearly three-quarters (73%) of p.r.n. medication administrations, no other therapeutic intervention was documented as occurring prior to administration.

The conceptualization of physical restraint as a nursing-sensitive adverse outcome in acute care psychiatric treatment settings

The occurrence of physical restraint episodes in psychiatric settings is a major public health issue because the therapeutic utility of this form of behavior control has not been substantiated empirically. The purpose of this article was to examine the extant literature to determine if evidence supports the conceptualization of a physical restraint episode as an adverse client outcome that is sensitive to the organization of nursing care in psychiatric settings. An adapted version of the Quality Health Outcomes Model (Mitchell, P. H., Ferketich, S., & Jennings, B. M. (1998). Quality Health Outcomes Model. Image Journal of Nursing Scholarship, 30, 43-46) was used as the conceptual model to guide this inquiry. The databases Cumulative Index to Nursing and Allied Health Literature, Health and Psychosocial Instruments, HealthSTAR/Ovid and Healthstar, Medline, and psychINFO were searched from 1990 to 2005. There are 101 sources in this review. Evidence strongly suggests that a physical restraint episode is an adverse outcome that is sensitive to the organization of nursing care. A systematic exploration of the specific structures and processes of the organization that affect adverse outcomes, such as physical restraint episodes, is lacking in the United States.

Coercive manoeuvres in a psychiatric intensive care unit

Coercive manoeuvres in a psychiatric intensive care unit The practice of physical restraint techniques in the management of disturbed behaviour is a significant part of the role of mental health nurses, particularly in Psychiatric Intensive Care Units (PICUs). Debate about what constitutes good practice is intense, and the subject of recently issued guidelines by National Institute for Mental Health in England. However, the contribution of other forms of conflict management techniques has tended to be ignored. The purpose of this study was to identify, describe and categorize coercive manoeuvres used by nurses, and to examine the circumstances and appropriateness of their use. Non-participant observation of verbal and non-verbal interaction between patients and nurses during conflict situations was undertaken on one PICU. The critical incidents observed were identified, categorized and systematically recorded. Nurses used a variety of low level physical and interactional manoeuvres in order to manage patients' disturbed and resistive behaviour. These manoeuvres were seldom recorded, discussed or reviewed, although they were frequently used to manage critical conflict situations. These manoeuvres have neither been previously described nor evaluated. They may, in some cases, be useful substitutes for actual restraint, alternatively they may, in some cases, be judged undesirable. It is not known how widespread these practices are in acute psychiatry.

The autonomy of professionals and the involvement of patients and families

PURPOSE OF REVIEW

The involvement of patients/service users and their families/caregivers in the field of mental health has been of interest for several years. It is timely to review what has been learned about involvement; to understand where and how involvement has been implemented; and to explore factors which influence the effectiveness of implementation. Recent literature on user involvement and its implications for professional practice forms the focus of this review. Material is drawn largely from Europe, North America and Australasia, since this reflects where there is most interest in this topic. Papers outside of mental health are included where they further illuminate issues under discussion.

RECENT FINDINGS

The involvement of users/patients and their caregivers is an important aspect of the care and treatment of mental illness extending across health and social care. Involvement has implications for professional practice including the negotiation of treatment, the coordination of care and communication strategies. Tensions may emerge during the process of effectively implementing patient/family involvement, but the autonomy of professionals is not usually a factor.

SUMMARY

There is no singular definition of involvement. There has been growth in the levels of user/caregiver involvement, particularly in community-based provision and within transition processes from hospital to community-based treatment. There is no suggestion that involvement is widespread. Implementation of involvement should be underpinned by effective communication on the part of professionals and recognition of service users and caregivers as partners in processes of treatment and recovery. Implementation is most effective when supported by appropriate organizational policies and integrated into the education of health professionals.