Developing a restraint-reduction program for child/adolescent inpatient treatment

Art therapy is associated with a reduction in restrictive practices on an inpatient child and adolescent mental health unit

BACKGROUND

The elimination of restrictive practices, such as seclusion and restraint, is a major aim of mental health services globally. The role of art therapy, a predominantly non-verbal mode of creative expression, is under-explored in this context. This research aimed to determine whether art therapy service provision was associated with a reduction in restrictive practices on an acute inpatient child and adolescent mental health services (CAMHS) unit.

METHODS

The rate (events per 1,000 occupied bed days), frequency (percent of admitted care episodes with incident), duration, and number of incidents of restrictive practices occurring between July 2015 and December 2021 were analysed relative to art therapy service provision. The rate, frequency and number of incidents of intramuscular injected (IM) sedation, oral PRN (as-needed medication) use, and absconding incidents occurring in conjunction with an episode of seclusion or restraint were also analysed.

RESULTS

The rate, frequency, duration, and total number of incidents of seclusion, the frequency and total number of incidents of physical restraint, and the rate, frequency and total number of incidents of IM sedation showed a statistically significant reduction during phases of art therapy service provision.

CONCLUSIONS

Art therapy service provision is associated with a reduction in restrictive practices in inpatient CAMHS.

Exploring perspectives on restraint during medical procedures in paediatric care: a qualitative interview study with nurses and physicians

The aim of this study was to explore nurses’ and physicians’ perspectives on and reasoning about the use of restraint during medical procedures on newly admitted preschoolers in somatic hospital care.

We analysed qualitative data from individual interviews with a video recall session at the end with seven physicians and eight nurses. They had earlier participated in video recorded peripheral vein cannulations on preschool children. The data were collected between May 2012 and May 2013 at a paediatric hospital unit in Norway.

The analysis resulted in three main themes: (1) disparate views on the concept of restraint and restraint use (2), ways to limit the use of physical restraint and its negative consequences, and (3) experience with the role of parents and their influence on restraint. Perspectives from both healthcare professions were represented in all the main themes and had many similarities.

The results of this study may facilitate more informed and reflective discussions of restraint and contribute to higher awareness of restraint in clinical practice. Lack of guidance and scientific attention to restraint combined with conflicting interests and values among healthcare providers may result in insecurity, individual dogmatism, and a lack of shared discussions, language, and terminology.

Reduction of Physical Restraints in Residential Treatment Facilities

Children and adolescents with severe emotional and behavioral problems in residential settings can become so aggressive that physical restraints are utilized to keep them and others safe. Recently, the use of physical restraints in residential treatment facilities for school-aged children has come under increased scrutiny, and there have been legislative mandates that the use of physical restraints be reduced. This article describes a quasi-experimental field study conducted to examine the effectiveness of a 2-phase (organizational and milieu) physical restraint reduction intervention in a multisite residential treatment center. Results provide support for the effectiveness of organizational-level and milieu interventions for restraint reduction. Overall, restraint rates were reduced by 59% using these interventions.

Frequency, characteristics and management of adolescent inpatient aggression

BACKGROUND

Inpatient aggression is a serious challenge in pediatric psychiatry.

METHODS

A chart review study in adolescent psychiatric inpatients consecutively admitted over 24 months was conducted, to describe aggressive events requiring an intervention (AERI) and to characterize their management. AERIs were identified based on specific institutional event forms and/or documentation of as-needed (STAT/PRN) medication administration for aggression, both recorded by nursing staff.

RESULTS

Among 408 adolescent inpatients (age: 15.2±1.6 years, 43.9% male), 1349 AERIs were recorded, with ≥1 AERI occurring in 28.4% (n=116; AERI+). However, the frequency of AERIs was highly skewed (median 4, range: 1-258). In a logistical regression model, the primary diagnosis at discharge of disruptive behavior disorders and bipolar disorders, history of previous inpatient treatment, length of hospitalization, and absence of a specific precipitant prior to admission were significantly associated with AERIs (R(2)=0.32; p<0.0001). The first line treatment of patients with AERIs (AERI+) was pharmacological in nature (95.6%). Seclusion or restraint (SRU) was used at least once in 59.4% of the AERI+ subgroup (i.e., in 16.9% of all patients; median within-group SRU frequency: 3). Treatment and discharge characteristics indicated a poorer prognosis in the AERI+ (discharge to residential care AERI+: 22.8%, AERI-: 5.6%, p<0.001) and a greater need for psychotropic polypharmacy (median number of psychotropic medications AERI+: 2; AERI-: 1, p<0.001).

CONCLUSIONS

Despite high rates of pharmacological interventions, SRU continue to be used in adolescent inpatient care. As both of these approaches lack a clear evidence base, and as adolescents with clinically significant inpatient aggression have increased illness acuity/severity and service needs, structured research into the most appropriate inpatient aggression management is sorely needed.

Management of aggressive behaviour among adolescents in forensic units: a four-country perspective

Management of aggressive behaviour is a challenge in adolescent forensic units. Aggressive behaviour endangers the safety of the treatment milieu for patients and nursing and multidisciplinary staff. However, there is a paucity of literature about how the staff manage aggressive behaviour among patients in adolescent forensic settings, and whether the nursing practices are similar across countries. The purpose of this study was to explore nursing practices used to manage adolescent aggressive behaviour in adolescent forensic units in four European countries. An exploratory, descriptive research approach was adopted for the study. A convenience sampling was used by selecting the staff members working in adolescent forensic units (Belgium n= 15, Finland n= 18, the Netherlands n= 16, the UK n= 9). Personal thematic interviews were used to collect the data; and for data analysis, qualitative content analysis was applied. Staff members preferred using verbal and less restrictive interventions when intervening in escalated situations and perceived the use of coercive measures as the last option. Differences between countries were found in the use of restrictive methods. The principles of aggression management were fairly similar across Europe, even if differences were reported in practical solutions.

Interventions to reduce the use of seclusion and restraint in inpatient psychiatric settings: what we know so far a review of the literature

INTRODUCTION

In recent times, much attention has been focused on the reduction of seclusion and restraint in psychiatric settings. This paper analyzes evidence available from evaluations of single seclusion and/or restraint reduction programmes. A total of 29 papers were included in the review.

RESULTS

Seven key strategy types emerged from the analysis: (i) policy change/leadership; (ii) external review/debriefing; (iii) data use; (iv) training; (v) consumer/family involvement; (vi) increase in staff ratio/crisis response teams; and (vii) programme elements/changes. Outcomes indicate that a range of reduction programmes are successful in reducing the frequency and duration of seclusion and restraint use, while at the same time maintaining a safe environment.

CONCLUSION

The development of new seclusion and restraint reduction programmes should include strong leadership from local management; external seclusion and restraint review committees or post-incident debriefing and analysis; broad-based staff training and programme changes at a local level. Behavioural and cognitive-behavioural programmes appear to be very useful in child and adolescent services. Further systematic research should be conducted to more fully understand which elements of successful programmes are the most powerful in reducing incidents of seclusion and restraint.

Violence and restraint reduction efforts on inpatient psychiatric units

Efforts to reduce aggression and violence and the use of restraint and seclusion have traditionally been through some form of educational program. This paper presents an integrative review of research and quality improvement projects that aimed to reduce aggression/violence or restraint/seclusion through the use of an educational program. Forty-six papers are included in this review. This paper presents summaries and comparisons of the research designs, the content and length of programs, and the outcomes of these programs. From these summaries, trends in relation to design, content, and outcomes are identified, and recommendations for clinicians and researchers are given.

Psychiatrists' views of compulsory psychiatric care of minors

Commitment to psychiatric care is in Finland allowed for minors in broader terms than for adults. Minors can be committed to and detained in involuntary psychiatric treatment if they suffer from severe mental disorder and fulfil the additional commitment criteria defined in the Mental Health Act. Adults can be committed to involuntary psychiatric care only if they are mentally ill (=psychotic), and fulfil the additional criteria. Involuntary treatment of minors has been increasing steadily since the Mental Health Act was passed in 1991. This study was set up to find out whether the Finnish child and adolescent psychiatrists agree with the need for defining broader commitment criteria for minors, and why. Semi-structured, reflexive dyadic interviews were carried out with 44 psychiatrists working with children and adolescents. The data was analysed using qualitative and quantitative content analysis. The analysis showed that broader commitment criteria for minors were favoured referring to developmental needs related to childhood and adolescence, prevention of mental illnesses and inadequacy of descriptive diagnosis in childhood and adolescence. The commitment criteria were rather seen as too narrow for adults than as too broad for minors, and the medical rights of minors were preferred over self-determination.

'It's part of the job, but it spoils the job': a phenomenological study of physical restraint

This paper examines mental health nurses' experiences of physical restraint in an acute inpatient psychiatric setting using Van Manen's descriptive hermeneutic phenomenological methodology. The aim was to understand the nurses' experiences of physical restraint. One overarching theme emerged from the analysis: It's part of the job. This theme had a subtheme of Control which was constituted by the Conflicted Nurse and the Scared Nurse. The findings suggest that mental health nurses are very uncomfortable with physical restraint despite it being taken-for-granted as integral to their role. The nurses experienced conflict and fear associated with the procedure and would prefer to utilize other de-escalation skills if it was possible. The main source of conflict related to the imperative to maintain control and the professional values of the therapeutic relationship. While the nurses could see no viable alternative in some situations, the paper concludes that while environmental issues impact on the practice of physical restraint mental health nurses need to practice it with as much care and humanity as possible.

Behavioral management leads to reduction in aggression in a child and adolescent psychiatric inpatient unit

OBJECTIVE

Aggression is common in children and adolescents admitted to psychiatric inpatient units. Few interventions for reducing aggressive behaviors have been identified. This study aimed to evaluate the impact of a milieu-based behavioral management program on the frequency of aggressive behaviors in a child and adolescent mental health inpatient unit.

METHOD

The behavioral management program incorporated individualized patient management plans, early detection and prevention, staff training, reinforcement of appropriate behaviors, and intervention using the least restrictive option. Outcomes were assessed for 6 months before and after program introduction, and included episodes of aggressive behavior, injuries, use of physical restraint, seclusion, p.r.n. sedation, use of security services, and staffing factors.

RESULTS

Implementation of behavioral management led to a significant reduction in the episodes of aggressive behavior (p < .05) and other unwanted outcomes including injuries (p < .05), use of physical restraint (p < .001), and duration of seclusion (p < .001). These outcomes were achieved without reducing the number of admissions, changing the types of patients admitted, increasing staff costs, or increasing the use of p.r.n. medications.

CONCLUSIONS

Aggressive behaviors in child and adolescent psychiatric inpatient units can be reduced by implementing a broad-based behavioral management program. These findings highlight the importance of organizational approaches to behavior and risk management.

Severe mental disorder as a basic commitment criterion for minors

Since 1991, commitment to involuntary psychiatric care has been allowed in Finland for minors in broader terms than for adults. While in adults mental illness has to be diagnosable before involuntary treatment can be imposed, minors can be committed to and detained in involuntary psychiatric treatment if they suffer from "severe mental disorders", and fulfil the further commitment criteria defined in the Mental Health Act. The first years of the new mental health legislation showed an increase in involuntary treatment of minors in Finland. Concerns were raised about the imprecise nature of the commitment criterion "severe mental illness". This study set out to find out whether Finnish child and adolescent psychiatrists are in agreement on how to define severe mental illness and whether their interpretations are sufficiently similar to ensure the equality of minors in commitment to psychiatric care as prescribed by the Mental Health Act. Semi-structured, reflexive dyadic interviews were carried out with 44 psychiatrists working with children and adolescents. The data was analysed using qualitative content analysis. There was general agreement about what constitutes a "severe mental disorder" justifying the involuntary psychiatric treatment of minors. The child and adolescent psychiatrists were of the opinion that involuntary treatment of minors should not be tied to specific diagnostic categories. Which disorders are severe enough to justify commitment should rather be considered through developmental and functional impairment and interactions between a minor and her/his environment.

Evidence base for practice: reduction of restraint and seclusion use during child and adolescent psychiatric inpatient treatment

BACKGROUND

Restraint and seclusion of children has great potential for harm. Since the mid-1980s, psychiatric inpatient personnel for children and adolescents have put considerable energy in reducing the use of extreme measures of aggression management. While the use of restraints is a particular problem in the United States, aggression management and means of control in psychiatric settings is an international issue.

APPROACH

The core question of this review was: What is the current state of the evidence supporting restraint reduction efforts with children and adolescents? Studies were reviewed and critiqued that related to programs of restraint reduction, restraint reduction methods, and aggression management. Internationally, there seems to be more emphasis on reducing coercive measures by understanding the context of their use. Thus, studies exploring staff perceptions and decisions concerning coercive measures were also examined.

FINDINGS

The evidence supporting restraint reduction methods in the United States comes mainly from case study reports of clinical sites' quality improvement projects. Consequently, a collection of studies is accumulating that supports a multi-strategy approach to restraint reduction. Limited evidence exists for aggression management measures and training in de-escalation techniques. Controversial aggression management techniques such as the use of pro re nata medication and holding continue to be used with very little support for their efficacy.

RECOMMENDATIONS

Recommendations include taking a view of restraint and seclusion as emergency measures to address dangerous aggression, not interventions examined in controlled studies. As such it is suggested that sites pool data on restraint use and reduction efforts to create a database for benchmarking and studying variations among hospitals. Furthermore, attention should also be given to developing additional means for addressing aggressive behaviors.

Seclusion use with children and adolescents: an Australian experience

OBJECTIVE

To summarize the current state of knowledge on the use of seclusion and restraint with children and adolescents and to report the findings of an exploratory study to identify factors that place a child or adolescent at increased risk of seclusion during their admission.

METHOD

Literature searches were undertaken on MEDLINE, CINAHL and PsycINFO databases. Articles were identified that focused specifically on seclusion and restraint use with children and adolescents or contained material significant to this population. The study reports findings from a retrospective review of patient charts, seclusion registers and staffing from an Australian acute inpatient facility.

RESULTS

The data available in regard to seclusion use in this population is limited and flawed. Further research is needed on the use and outcomes of seclusion and restraint and on alternative measures in the containment of dangerousness. Both the literature and this study find that patients with certain factors are at increased risk of being secluded during an inpatient stay. These factors include being male, diagnoses of disruptive behaviour disorder and a previous history of physical abuse. Staffing factors did not show a relationship to the use of seclusion.

CONCLUSIONS

There are patient factors that predict increased risk of seclusion; these factors and their interrelationships require further elucidation. Further research is also needed on the outcomes, both positive and negative, of seclusion use and of alternatives to seclusion.

Adverse effects associated with physical restraint

OBJECTIVE

Restraint use is not monitored in the US, and only institutions that choose to do so collect statistics. In 1999, investigative journalists reported lethal consequences proximal to restraint use, making it a life-and-death matter that demands attention from professionals. This paper reviews the literature concerning actual and potential causes of deaths proximal to the use of physical restraint.

METHOD

Searching the electronic databases Medline, Cinahl, and PsycINFO, we reviewed the areas of forensics and pathology, nursing, cardiology, immunology, psychology, neurosciences, psychiatry, emergency medicine, and sports medicine.

CONCLUSIONS

Research is needed to provide clinicians with data on the risk factors and adverse effects associated with restraint use, as well as data on procedures that will lead to reduced use. Research is needed to determine what individual risk factors and combinations thereof contribute to injury and death.

De-escalating aggression and violence in the mental health setting

Aggressive and violent incidents in the health-care setting are increasing phenomena around the world. The evidence from current literature suggests that changes in health-care access, nursing staff shortages and patient acuity are some of the possible causes. De-escalation is a valuable intervention that can be used by nurses to help counter the growing problems of aggression and violence. The de-escalation project, discussed in the present paper, aimed to explore de-escalation as an important therapeutic process and is an event of considerable potential in the management of aggression and violence. While de-escalation is not a new tool, particularly in the mental health-care setting, an educative programme aimed at renewing nurses' knowledge and skills in de-escalation is a timely project. The final de-escalation kit included a large glossy poster, a nursing staff survey, an in-service education session and a literature-based discussion paper. The de-escalation kit can be of considerable benefit to those nurses who are transient within the workplace, such as casual and agency nurses.