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Cole C, Klotz E, Junghanss J, Oster A, Bermpohl F, Vandamme A, Mahler L. Patient communication ability as predictor of involuntary admission and coercive measures in psychiatric inpatient treatment. J Psychiatr Res 2022; 153:11-17. [PMID: 35792341 DOI: 10.1016/j.jpsychires.2022.06.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/30/2022] [Accepted: 06/24/2022] [Indexed: 10/17/2022]
Abstract
Coercive measures (CM) and involuntary admission to psychiatric treatment can have detrimental consequences for patients. Past research shows that certain clinical, treatment and admission-related characteristics put patients at a higher risk of experiencing CM and involuntary admission. Although of high societal importance, the association between patients' communication ability and CM and involuntary admission has not been subject of past research. To explicitly examine this association the authors conducted a retrospective study using data from patients admitted to psychiatric inpatient treatment via the emergency room at Charité St. Hedwig Hospital, Berlin in 2019. As independent variable, communication ability at admission was recorded (perfect; limited due to language or other reasons; impossible due to language or other reasons) along with possibly confounding variables including demographic, clinical and admission-related details. As dependent variables, involuntary admission and CM were recorded. Multivariate logistic regression analyses were conducted examining the association between communication ability and involuntary admission and CM. In a sample of N = 1556, controlling for potential confounders, limited (OR = 3.08; p = .004) or no communication ability (OR = 4.02; p = .003) due to language barrier or limited (OR = 3.10; p < .001) or no communication ability (OR = 13.71; p < .001) due to other factors were significant predictors for involuntary admission. Limited communication ability due to language barrier (OR = 4.53; p < .001) and limited (OR = 1.58; p = .034) and no communication ability (OR = 3.55; p < .001) due to other factors were significant predictors for CM. These findings show that patients impaired in their communication ability are at higher risk of involuntary admission and CM and highlight the urgency of implementing appropriate interventions facilitating communication during admission and treatment.
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Affiliation(s)
- Celline Cole
- Charité University Medicine Berlin, Department of Psychiatry at St. Hedwig Hospital (PUK Charité im SHK), Grosse Hamburger Str. 5-11, 10115, Berlin, Germany.
| | - Eva Klotz
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | - Julia Junghanss
- Charité University Medicine Berlin, Department of Psychiatry at St. Hedwig Hospital (PUK Charité im SHK), Grosse Hamburger Str. 5-11, 10115, Berlin, Germany
| | - Anna Oster
- Department of Psychiatry and Psychotherapy, Clinics in the Theodor-Wenzel-Werk, Potsdamer Chaussee 69, 14129, Berlin, Germany
| | - Felix Bermpohl
- Charité University Medicine Berlin, Department of Psychiatry at St. Hedwig Hospital (PUK Charité im SHK), Grosse Hamburger Str. 5-11, 10115, Berlin, Germany
| | - Angelika Vandamme
- Charité University Medicine Berlin, Department of Psychiatry at St. Hedwig Hospital (PUK Charité im SHK), Grosse Hamburger Str. 5-11, 10115, Berlin, Germany
| | - Lieselotte Mahler
- Charité University Medicine Berlin, Department of Psychiatry at St. Hedwig Hospital (PUK Charité im SHK), Grosse Hamburger Str. 5-11, 10115, Berlin, Germany; Department of Psychiatry and Psychotherapy, Clinics in the Theodor-Wenzel-Werk, Potsdamer Chaussee 69, 14129, Berlin, Germany
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Pérez-Toribio A, Moreno-Poyato AR, Lluch-Canut T, Molina-Martínez L, Bastidas-Salvadó A, Puig-Llobet M, Roldán-Merino JF. Relationship between nurses' use of verbal de-escalation and mechanical restraint in acute inpatient mental health care: a retrospective study. Int J Ment Health Nurs 2022; 31:339-347. [PMID: 34837275 DOI: 10.1111/inm.12961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/08/2021] [Accepted: 11/14/2021] [Indexed: 11/29/2022]
Abstract
Although the use of verbal de-escalation in nursing has been shown to be an effective tool for controlling agitation and avoiding mechanical restraint, there is scarce evidence supporting the use of de-escalation by nurses and factors related to the patients who ultimately receive mechanical restraint. This retrospective study sought to examine the relationship between the use of verbal de-escalation by nurses and the clinical profile of patients who had received mechanical restraint at an acute mental health unit. This study analysed the records of patients who had received mechanical restraint between the years 2012 and 2019. A bivariate analysis was initially performed, followed by multiple logistic regression analysis. A total of 493 episodes of restraint were recorded. Of these, in almost 40% of cases, no prior use of verbal de-escalation was noted. The factors associated with the use of verbal de-escalation by nurses were patients with a history of restraint episodes and patients who previously had been administered medication. Furthermore, episodes of mechanical restraint that occurred later during the admission were also associated with the use of de-escalation. These findings confirm the relevance of early nurse interventions. Consequently, it is important to establish an adequate therapeutic relationship from the start of hospitalization to facilitate getting to know the patient and to enable the timely use of verbal de-escalation, thus avoiding the use of mechanical restraint.
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Affiliation(s)
- Alonso Pérez-Toribio
- Unitat de Salut Mental de l'Hospitalet, Servei d'Atenció Primària Delta de Llobregat / Direcció d'Atenció Primària Costa de Ponent, Institut Català de la Salut, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Antonio R Moreno-Poyato
- Department of Public Health, Mental Health and Maternal and Child Health Nursing, Nursing School, Universitat de Barcelona, L´Hospitalet de Llobregat, Barcelona, Spain
| | - Teresa Lluch-Canut
- Department of Public Health, Mental Health and Maternal and Child Health Nursing, Nursing School, Universitat de Barcelona, L´Hospitalet de Llobregat, Barcelona, Spain
| | - Laura Molina-Martínez
- Programa Atención Domiciliaria Intensivo (PADI), Associació d'Higiene Mental Nou Barris, Barcelona, Spain
| | | | - Montserrat Puig-Llobet
- Department of Public Health, Mental Health and Maternal and Child Health Nursing, Nursing School, Universitat de Barcelona, L´Hospitalet de Llobregat, Barcelona, Spain
| | - Juan F Roldán-Merino
- Campus Docent Sant Joan de Déu Fundació Privada, School of Nursing, University of Barcelona, Barcelona, Spain
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Celofiga A, Kores Plesnicar B, Koprivsek J, Moskon M, Benkovic D, Gregoric Kumperscak H. Effectiveness of De-Escalation in Reducing Aggression and Coercion in Acute Psychiatric Units. A Cluster Randomized Study. Front Psychiatry 2022; 13:856153. [PMID: 35463507 PMCID: PMC9021532 DOI: 10.3389/fpsyt.2022.856153] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 02/28/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Most guidelines for the management of aggressive behavior in acute psychiatric patients describe the use of de-escalation as the first-choice method, but the evidence for its effectiveness is inconsistent. The aim of the study was to assess the effect of verbal and non-verbal de-escalation on the incidence and severity of aggression and the use of physical restraints in acute psychiatric wards. METHODS A multi-center cluster randomized study was conducted in the acute wards of all psychiatric hospitals in Slovenia. The research was carried out in two phases, a baseline period of five consecutive months and an intervention period of the same five consecutive months in the following year. The intervention was implemented after the baseline period and included training in verbal and non-verbal de-escalation techniques for the staff teams on experimental wards. RESULTS In the baseline study period, there were no significant differences in the incidence of aggressive behavior and physical restraints between the experimental and control groups. The incidence rates of aggressive events, severe aggressive events, and physical restraints per 100 treatment days decreased significantly after the intervention. Compared to the control group, the incidence rate of aggressive events was 73% lower in the experimental group (IRR = 0.268, 95% CI [0.221; 0.342]), while the rate of severe events was 86% lower (IRR = 0.142, 95% CI [0.107; 0.189]). During the intervention period, the incidence rate of physical restraints due to aggression in the experimental group decreased to 30% of the rate in the control group (IRR = 0.304, 95% CI [0.238; 0.386]). No reduction in the incidence of restraint used for reasons unrelated to aggression was observed. After the intervention, a statistically significant decrease in the severity of aggressive incidents (p < 0.001) was observed, while the average duration of restraint episodes did not decrease. CONCLUSION De-escalation training is effective in reducing the incidence and severity of aggression and the use of physical restraints in acute psychiatric units. CLINICAL TRIAL REGISTRATION [www.ClinicalTrials.gov], identifier [NCT05166278].
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Affiliation(s)
- Andreja Celofiga
- Department of Psychiatry, University Medical Centre Maribor, Maribor, Slovenia.,Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Blanka Kores Plesnicar
- University Psychiatric Clinic Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Jure Koprivsek
- Department of Psychiatry, University Medical Centre Maribor, Maribor, Slovenia
| | - Miha Moskon
- Faculty of Computer and Information Science, University of Ljubljana, Ljubljana, Slovenia
| | - Dominik Benkovic
- Faculty of Natural Sciences and Mathematics, University of Maribor, Maribor, Slovenia
| | - Hojka Gregoric Kumperscak
- Faculty of Medicine, University of Maribor, Maribor, Slovenia.,Child and Adolescent Psychiatry Unit, University Medical Centre Maribor, Maribor, Slovenia
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Konttila J, Holopainen A, Pesonen HM, Kyngäs H. Occurrence of workplace violence and the psychological consequences of it among nurses working in psychiatric outpatient settings. J Psychiatr Ment Health Nurs 2021; 28:706-720. [PMID: 33306239 DOI: 10.1111/jpm.12723] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 10/16/2020] [Accepted: 12/01/2020] [Indexed: 02/03/2023]
Abstract
WHAT IS KNOWN ON THE SUBJECT?: There is a scarcity of studies concerning violence in psychiatric outpatient settings in the 2010s in spite of the deinstitutionalization of psychiatric services. Previous research on violence in psychiatric outpatient settings has failed to consider the association between the psychological consequences of violence, exposures to violence and background factors. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: It has been known for some time that exposures to violence are harmful for psychiatric inpatient nurses; the paper demonstrates that psychiatric outpatient nurses are also at risk. The psychological consequences of exposure to violence are highly individualized and influenced by background factors. Nurses who face harassment have a greater risk of suffering psychological symptoms. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: De-escalation interventions should be implemented in psychiatric outpatient settings. Organizations should consider the possibility of internal violence occurring when planning preventive interventions to manage and reduce workplace violence. Education targeted at violence prevention, management and debriefing should be organized systematically in psychiatric outpatient units and be taken into consideration in the mental health nursing curriculum. ABSTRACT: Introduction There is a scarcity of studies concerning violence and its consequences in psychiatric outpatient setting. Aim This study aimed to explore the occurrence of workplace violence and the psychological consequences of exposure to violence among nurses working in psychiatric outpatient settings. Method Research followed a cross-sectional survey design. Data were collected with the VIA-Q instrument. Results During the 12 months prior to the study, nurses (n = 181) had most often experienced psychological violence, with fatigue being the most common consequence. Harassment most often caused feelings of violated integrity, whereas physical violence most often caused insomnia. Significant relationships between exposure to violence and psychological consequences were identified. Discussion Workplace violence can manifest in a broad array of psychological symptoms and be harmful for nurses in psychiatric outpatient settings. It is important to discuss the subject of workplace violence and its place in the nursing curriculum and to reflect on how nurses are educated and trained to face violence in psychiatric nursing. Implications for Practice De-escalation interventions should be implemented in psychiatric outpatient settings. Organizations should take steps to abolish internal violence. Nurses need appropriate education in order to prepare them to manage workplace violence.
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Affiliation(s)
- Jenni Konttila
- Faculty of Medicine, Research Unit of Nursing Science and Health Management, Medical Research Center, University of Oulu Finland, Oulu, Finland.,University Hospital of Oulu, Oulu, Finland
| | - Arja Holopainen
- Nursing Research Foundation/The Finnish Centre for Evidence-Based Health Care: A Joanna Briggs Institute Affiliated Group, Helsinki, Finland
| | | | - Helvi Kyngäs
- Faculty of Medicine, Research Unit of Nursing Science and Health Management, Medical Research Center, University of Oulu Finland, Oulu, Finland.,University Hospital of Oulu, Oulu, Finland
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Tölli S, Kontio R, Partanen P, Häggman-Laitila A. Conceptual framework for a comprehensive competence in managing challenging behaviour: The views of trained instructors. J Psychiatr Ment Health Nurs 2021; 28:692-705. [PMID: 33295055 DOI: 10.1111/jpm.12722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 10/10/2020] [Accepted: 11/30/2020] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN ON THE SUBJECT?: There is body of knowledge available about the harms associated with restrictive interventions used in behaviour management, service users' perceptions of the use of restraints, and staff competence in behaviour management. The staff perspective has been studied in terms of staff exposure, responses to and prevention of aggression, staff-related factors associated with service user aggression, and staff attitudes and perceptions towards violence. The definitions of competence in behaviour management provided in training interventions are fragmented and based on unilateral measurements. Training interventions with the purpose of enhancing staff competence in behaviour management are organized regularly, yet there is a lack of clarity on how effective these interventions are. Inadequate conceptual understanding of behaviour management can weaken the effectiveness of these interventions. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Our study produced new knowledge by providing a preliminary conceptual framework that can be used to comprehensively describe and assess competence in managing challenging behaviour and to cover safely the whole care process. Humane care and ethical sensitivity should be the premises of interaction with people in distress. We also pointed out the needs for conceptual clarification of the concepts of confidence, support and restraint. We provide important new insight into the leadership and cultural issues of behaviour management that is relevant for patients, staff members and healthcare organizations. We found that staff members do not consider service user safety and workplace safety as opposing issues. Further, we provide new perspectives for prevention, the risk assessment process and effective communication in the context of behaviour management. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: A comprehensive understanding of the competences related to behaviour management will foster universal definitions for "support" and "restraint," which can then be used to ensure that the best practices are used for behaviour management. Organizational culture and participative leadership on behaviour management should be developed with a special focus on safety issues, common understanding of comprehensive competence, risk assessment and prevention, views regarding the use of restraints, and teamwork. ABSTRACT: Introduction Previous research concerning staff views of behaviour management has not considered instructors' views. The definitions of competence in behaviour management are fragmented, which can undermine the effectiveness of training interventions. Aim/Question This study aimed to describe Finnish and British Management of Actual or Potential Aggression instructors' perceptions of safety and behaviour management-related competences and create a conceptual framework for comprehensive competence. Method An explorative-descriptive qualitative approach with purposive sampling (N = 22), semi-structured interviews and abductive content analysis. Results Conceptual framework of comprehensive competence in managing challenging behaviour includes five categories-knowledge, skills, attitude, confidence and ethical sensitivity-and 21 subcategories. Competent staff and supportive leadership ensured safety, while inconsistent risk management culture, the health and behaviour of service users, and inadequate staff orientation endangered safety. Discussion The study produced new knowledge of safety issues and competences from the perspective of the instructors who deliver behaviour management training. Implications for practice Competence to manage challenging behaviour should be developed based on our conceptual framework to provide an effective and safe training. Prevention, the risk assessment process, alternative communication, and the definitions of "confidence," "support" and "restraint" should all be sufficiently addressed in future training.
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Affiliation(s)
- Sirpa Tölli
- University of Eastern Finland, Kuopio, Finland.,Oulu University of Applied Sciences, Oulu, Finland
| | - Raija Kontio
- Director Hyvinkää Hospital, Adjunct Professor Helsinki University, Helsinki, Finland
| | | | - Arja Häggman-Laitila
- University of Eastern Finland, Kuopio, Finland.,Social and Health Care, City of Helsinki, Helsinki, Finland
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Donner L, Wiklund Gustin L. Navigating between Compassion and Uncertainty - Psychiatric Nurses' Lived Experiences of Communication with Patients Who Rarely Speak. Issues Ment Health Nurs 2021; 42:307-316. [PMID: 32790482 DOI: 10.1080/01612840.2020.1793246] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Caring conversations are considered essential in psychiatric and mental health nursing. However, some patients are more or less silent and rarely express themselves verbally. This can be challenging for nurses who also need to find ways of communicating with these patients. Therefore, the aim of this study is to describe psychiatric nurses' lived experiences of communication with patients who rarely speak. Five nurses were recruited from a psychiatric nursing home. Participants were encouraged in interviews to reflect on their experiences of caring for patients who are more or less silent. The transcribed interviews were subject to a phenomenological hermeneutic analysis. The findings are reflected in three main themes: (i) giving space for the unspoken narrative, (ii) remaining in uncertainty, and (iii) being in reflective vigilance. The themes were synthesised and reflected on in the light of Fredriksson's theory of caring conversations. The comprehensive understanding reveals that nurses' understanding of the patient's unspoken narrative relies both on compassion and a willingness to engage, but also on a preparedness to remain in the uncertainty of not knowing. Balancing good intentions and the fear of one's own shortcomings requires reflections not only in actions during encounters with the patient, but on actions. When nurses can apprehend and respond to what the patient expresses non-verbally, a joint narrative can emerge.
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Affiliation(s)
- Lucas Donner
- Stiftelsen Hemmet ("The Home Foundation"), Lemland, Finland.,School of Health, Care and Social Welfare, Mälardalen University Sweden, Västerås, Sweden
| | - Lena Wiklund Gustin
- School of Health, Care and Social Welfare, Mälardalen University Sweden, Västerås, Sweden.,Department of Health and Care Sciences, UiT/The Arctic University of Norway, Tromsø, Norway
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Legambi TF, Doede M, Michael K, Zaleski M. A Quality Improvement Project on Agitation Management in the Emergency Department. J Emerg Nurs 2021; 47:390-399.e3. [PMID: 33648736 DOI: 10.1016/j.jen.2021.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 01/07/2021] [Accepted: 01/11/2021] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Agitation is common in the emergency department. When agitation is not detected early, patients can become aggressive and violent, potentially leading to restraint use and subsequent injury. The goals of the project were early detection and management of patient agitation, reduction of restraint use in the emergency department, and determination of the usability of the Behavioral Activity Rating Scale. METHODS This quality improvement project was assessed using a pre- and posttest single unit design, comparing 4 months of postimplementation data to historic controls at the same time of year in the previous year. The intervention was implementing the Behavioral Activity Rating Scale in the ED electronic medical record. Data were collected through retrospective chart review and nurse survey. From September through December of both 2017 and 2018, data were collected on restraint use. The 4-month 2018 data collection period included measures of Behavioral Activity Rating Scale documentation and the System Usability Scale survey for nurses to measure ease of usability of the Behavioral Activity Rating Scale. RESULTS The Behavioral Activity Rating Scale was documented frequently (n = 4 867 documentations) by emergency nurses to assess patients with behavioral health and medical complaints (n = 780). Nurses identified 18 episodes of violent behavior in behavioral health patients on the Behavioral Activity Rating Scale (2.31%) and applied restraints 18 times. The most common chief complaints for patients who were identified as violent was suicidal ideation (n = 6; 33.33%). In 2017, there were 20 episodes of restraint use during the same time period, a nonsignificant difference (χ2 = 0.72; P = 0.40). However, only 2 patients were kept in restraints longer than 1 day in 2018 compared with 8 in 2017. Emergency nurses found the Behavioral Activity Rating Scale to be usable in the structured usability assessment (μ = 83.46; SD = 11.73). DISCUSSION The Behavioral Activity Rating Scale is a usable tool for emergency nurses to assess for patient agitation. With the incorporation of agitation management interventions, the ED team can potentially manage agitation before violence occurs. Further studies are needed on the use of agitation or aggression assessment tools for managing patient behavioral activity such as aggression in the emergency department.
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Asikainen J, Louheranta O, Vehviläinen-Julkunen K, Repo-Tiihonen E. Use of coercion prevention tools in Finnish psychiatric wards. Arch Psychiatr Nurs 2020; 34:412-420. [PMID: 33032767 DOI: 10.1016/j.apnu.2020.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/13/2020] [Accepted: 07/03/2020] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Jaana Asikainen
- Niuvanniemi Hospital, Department of Forensic Psychiatry, University of Eastern Finland, Niuvankuja 65, FI-70240 Kuopio, Finland.
| | - Olavi Louheranta
- Niuvanniemi Hospital, Department of Forensic Psychiatry, University of Eastern Finland, Niuvankuja 65, FI-70240 Kuopio, Finland.
| | | | - Eila Repo-Tiihonen
- Niuvanniemi Hospital, Department of Forensic Psychiatry, University of Eastern Finland, Niuvankuja 65, FI-70240 Kuopio, Finland
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Ye J, Xiao A, Wang C, Xia Z, Yu L, Li S, Lin J, Liao Y, Xu Y, Zhang YL. Evaluating the effectiveness of a CRSCE-based de-escalation training program among psychiatric nurses: a study protocol for a cluster randomized controlled trial. BMC Health Serv Res 2020; 20:642. [PMID: 32650760 PMCID: PMC7350652 DOI: 10.1186/s12913-020-05506-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 07/02/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The high incidence of workplace violence (WPV) in clinical mental health settings has caused a series of negative impacts on nurses, which has subsequently increased public concern. De-escalation (DE) is recommended as a training program which aims at providing nurses with skills and strategies to more effectively respond and manage WPV. Very few studies have examined the effectiveness of DE training, with current studies possessing various limitations due to their design and small sample sizes. By using a cluster randomized controlled design, the proposed study aims to evaluate the effectiveness of a CRCSE-based DE training programs among psychiatric nurses. METHOD A cluster randomized controlled trial, with a 6-month follow-up period after the end of the intervention, will be conducted among psychiatric hospitals in Guangdong, China. The randomization unit is each involved psychiatric hospital. Participants in the control group will be assigned to routine WPV management training, participants of the intervention group will undergo the same training while additionally receiving DE training. The DE training will include the following five modules: communication, response, solution, care, and environment (CRSCE). Primary outcomes are objective clinical indicators, which will be extracted from the information systems of the enrolled hospitals. These include the incidence of WPV, injuries caused by WPV, and the use of coercion (physical restraint and seclusion) by nurses. Secondary outcomes, aims at evaluating the effects of DE training on nurses, include the capacity of DE, DE confidence, level of job burnout, and professional quality of life. Data will be collected at baseline (T0), at 3 months (T1, intervention completed), and at 6 months after intervention (T2, follow-up). DISCUSSION This study will offer trial-based evidence of the efficacy of a DE training program targeted at WPV among psychiatric nurses. DE training is expected to reduce both the total incidence and negative impacts of WPV, with additional improvements in psychiatric nurses' coping skills. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR1900022211 . Prospectively registered on 30 March 2019.
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Affiliation(s)
- Junrong Ye
- Department of Nursing Administration, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China.
- Department of Social Psychiatry, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China.
| | - Aixiang Xiao
- Department of Nursing Administration, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China
- Department of Traditional Chinese Medicine, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Chen Wang
- Department of Early Intervention, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Zhichun Xia
- Department of Adult Psychiatry, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Lin Yu
- Department of Traditional Chinese Medicine, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Sijue Li
- Department of Nursing Administration, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China
- Department of Traditional Chinese Medicine, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Jiankui Lin
- Department of Nursing Administration, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, 510370, China
| | - Yao Liao
- Department of Cardiothoracic Surgery, Jingzhou Central Hospital, Jingzhou, China
| | - Yu Xu
- Department of Intensive Care Unit, West China Hospital of Sichuan University, Chengdu, China
| | - Yun Lei Zhang
- Department of Cardiothoracic Surgery, Jingzhou Central Hospital, Jingzhou, China
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10
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Zheng C, Li S, Chen Y, Ye J, Xiao A, Xia Z, Liao Y, Xu Y, Zhang Y, Yu L, Wang C, Lin J. Ethical consideration on use of seclusion in mental health services. Int J Nurs Sci 2019; 7:116-120. [PMID: 32099869 PMCID: PMC7031114 DOI: 10.1016/j.ijnss.2019.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 09/04/2019] [Accepted: 10/11/2019] [Indexed: 02/05/2023] Open
Abstract
Seclusion was widely used in mental health service, which had caused various negative effects on patients and nurses. In China, the clinical use of seclusion was gradually increasing, which had led to ethical dilemma and had gained public concern. This article aimed to synthesize the ethical issue according to the principle of autonomy, justice, beneficence, and non-maleficence. Given that nursing workforce was limited and work burden among psychiatric nurses was heavy, seclusion was one of coercive interventions managing aggressive behavior. In relation to cope with ethical dilemma, it was proposed to improve therapeutic environment, and to apply de-escalation technique. Additionally, reducing clinical use and adverse effects of seclusion was also important, this goal would be achieved by building appropriate patient-nurse relationship, increasing staff engagement, and promoting guideline of seclusion.
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Affiliation(s)
- Chaodun Zheng
- Department of Early Intervention, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Sijue Li
- Department of Nursing Administration, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China.,Department of Traditional Chinese Medicine, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Yingmei Chen
- Department of Early Intervention, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Junrong Ye
- Department of Nursing Administration, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China.,Department of Traditional Chinese Medicine, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Aixiang Xiao
- Department of Nursing Administration, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China.,Department of Traditional Chinese Medicine, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Zhichun Xia
- Department of Nursing Administration, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Yao Liao
- Department of Nursing Administration, Jingzhou Central Hospital, Jingzhou, China
| | - Yu Xu
- Department of Intensive Care Unit, West China Hospital of Sichuan University, Chengdu, China
| | - Yunlei Zhang
- Department of Nursing Administration, Jingzhou Central Hospital, Jingzhou, China
| | - Lin Yu
- Department of Nursing Administration, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Chen Wang
- Department of Early Intervention, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Jiankui Lin
- Department of Nursing Administration, Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
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11
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Forsyth AS, Trevarrow R. Sensory strategies in adult mental health: A qualitative exploration of staff perspectives following the introduction of a sensory room on a male adult acute ward. Int J Ment Health Nurs 2018; 27:1689-1697. [PMID: 29663648 DOI: 10.1111/inm.12466] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2018] [Indexed: 12/01/2022]
Abstract
In recent years, there has been growing interest in the use of sensory techniques to help with emotional regulation in adult mental health populations. This is against a backdrop of international policies aimed at reducing restrictive interventions and improving the effectiveness of de-escalation techniques. A sensory room was designed and implemented on a male adult acute psychiatric ward. Staff perspectives were sought to evaluate the effectiveness of the room in managing emotional distress by exploring staff awareness of a broader range of de-escalation strategies and by exploring what effect the room had on staff behaviours with respect to sensory interventions. A series of semi-structured interviews were carried out, analysed, and grouped into themes. Three themes emerged as follows: enhancing de-escalation, sensory interventions, and impact on staff. Findings showed that increased awareness of sensory processing and use of sensory strategies such as the sensory room were perceived by staff to have a positive impact on reducing distress with male service users. Staff use of the room was also discovered to have benefits that included staff attending to their own emotional needs and the use of the room supporting reflective learning during critical incident debriefing.
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Affiliation(s)
- Angus S Forsyth
- University of Sunderland, Sunderland, UK.,Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Rebecca Trevarrow
- University of Sunderland, Sunderland, UK.,Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
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12
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Patel MX, Sethi FN, Barnes TR, Dix R, Dratcu L, Fox B, Garriga M, Haste JC, Kahl KG, Lingford-Hughes A, McAllister-Williams H, O'Brien A, Parker C, Paterson B, Paton C, Posporelis S, Taylor DM, Vieta E, Völlm B, Wilson-Jones C, Woods L. Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation. J Psychopharmacol 2018; 32:601-640. [PMID: 29882463 DOI: 10.1177/0269881118776738] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The British Association for Psychopharmacology and the National Association of Psychiatric Intensive Care and Low Secure Units developed this joint evidence-based consensus guideline for the clinical management of acute disturbance. It includes recommendations for clinical practice and an algorithm to guide treatment by healthcare professionals with various options outlined according to their route of administration and category of evidence. Fundamental overarching principles are included and highlight the importance of treating the underlying disorder. There is a focus on three key interventions: de-escalation, pharmacological interventions pre-rapid tranquillisation and rapid tranquillisation (intramuscular and intravenous). Most of the evidence reviewed relates to emergency psychiatric care or acute psychiatric adult inpatient care, although we also sought evidence relevant to other common clinical settings including the general acute hospital and forensic psychiatry. We conclude that the variety of options available for the management of acute disturbance goes beyond the standard choices of lorazepam, haloperidol and promethazine and includes oral-inhaled loxapine, buccal midazolam, as well as a number of oral antipsychotics in addition to parenteral options of intramuscular aripiprazole, intramuscular droperidol and intramuscular olanzapine. Intravenous options, for settings where resuscitation equipment and trained staff are available to manage medical emergencies, are also included.
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Affiliation(s)
- Maxine X Patel
- 1 Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Faisil N Sethi
- 2 Maudsley Hospital, South London and Maudsley NHS Foundation Trust, London, UK
| | - Thomas Re Barnes
- 3 The Centre for Psychiatry, Imperial College London, London, UK
| | - Roland Dix
- 4 Wotton Lawn Hospital, together NHS Foundation Trust, Gloucester, UK
| | - Luiz Dratcu
- 5 Maudsley Hospital, South London and Maudsley NHS Foundation Trust, London, UK
| | - Bernard Fox
- 6 National Association of Psychiatric Intensive Care Units, East Kilbride, Glasgow, UK
| | - Marina Garriga
- 7 Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
| | - Julie C Haste
- 8 Mill View Hospital, Sussex Partnership NHS Foundation Trust, Hove, East Sussex, UK
| | - Kai G Kahl
- 9 Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hanover, Germany
| | - Anne Lingford-Hughes
- 10 The Centre for Psychiatry, Imperial College London, London, UK and Central North West London NHS Foundation Trust, London, UK
| | - Hamish McAllister-Williams
- 11 Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.,12 Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Aileen O'Brien
- 13 South West London and St Georges NHS Foundation Trust, London, UK and St George's University of London, London, UK
| | - Caroline Parker
- 14 Central & North West London NHS Foundation Trust, London, UK
| | | | - Carol Paton
- 16 Oxleas NHS Foundation Trust, Dartford, UK
| | - Sotiris Posporelis
- 17 South London and Maudsley NHS Foundation Trust, London, UK and Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - David M Taylor
- 18 South London and Maudsley NHS Foundation Trust, London, UK
| | - Eduard Vieta
- 7 Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
| | - Birgit Völlm
- 19 Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, UK
| | | | - Laura Woods
- 21 The Hellingly Centre, Forensic Health Care Services, Sussex Partnership NHS Foundation Trust, East Sussex, UK
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13
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Price O, Baker J, Bee P, Lovell K. The support-control continuum: An investigation of staff perspectives on factors influencing the success or failure of de-escalation techniques for the management of violence and aggression in mental health settings. Int J Nurs Stud 2018; 77:197-206. [DOI: 10.1016/j.ijnurstu.2017.10.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 10/04/2017] [Accepted: 10/05/2017] [Indexed: 11/28/2022]
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14
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Price O, Baker J, Bee P, Grundy A, Scott A, Butler D, Cree L, Lovell K. Patient perspectives on barriers and enablers to the use and effectiveness of de-escalation techniques for the management of violence and aggression in mental health settings. J Adv Nurs 2017; 74:614-625. [PMID: 29082552 DOI: 10.1111/jan.13488] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2017] [Indexed: 11/28/2022]
Abstract
AIM Investigate patient perspectives on barriers and enablers to the use and effectiveness of de-escalation techniques for aggression in mental health settings. BACKGROUND De-escalation techniques are the recommended first-line intervention for the management of aggression in mental health settings internationally, yet use of higher risk restrictive practices persists. This indicates de-escalation techniques are not used at optimum frequency and/or there are important factors limiting their use and effect. DESIGN Descriptive qualitative research using semi-structured interviews and Framework Analysis. METHODS Inpatient interviews (N = 26) exploring staff, patient and environmental factors influencing the use and effectiveness of staff de-escalation were conducted mid-2014. Three service user researchers led analysis. RESULTS Data were synthesized in three deductive themes relating to staff, patient and environmental influences on the use and effectiveness of de-escalation techniques. The dominant view was that restrictive practices, rather than de-escalation techniques, are used in response to escalating patient behaviour. Under-use of de-escalation techniques was attributed to: lack of staff reflection on culture and practice and a need to retain control/dominance over patients. Ward rules, patient factors and a lack of staff respect for patients diluted their effectiveness. Participants identified a systematic process of de-escalation, rule subversion, reduced social distance and staff authenticity as enablers of effective de-escalation. CONCLUSION This study investigated patient perspectives on staff, patient and environmental influences on the use and effectiveness of de-escalation techniques. Our framework of barriers and enablers provides indicators of organizational/behaviour change targets for interventions seeking to reduce violence and restrictive practices through enhanced de-escalation techniques.
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Affiliation(s)
- Owen Price
- Mental Health Nursing, University of Manchester, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - John Baker
- Mental Health Nursing, University of Leeds, Leeds, UK
| | - Penny Bee
- Mental Health Services Research, University of Manchester, Manchester, UK
| | - Andrew Grundy
- Mental Health Services Research, University of Nottingham, Nottingham, UK
| | - Anne Scott
- Mental Health Services Research, University of Manchester, Manchester, UK
| | - Debbie Butler
- Mental Health Services Research, University of Nottingham, Nottingham, UK
| | - Lindsey Cree
- Mental Health Services Research, University of Manchester, Manchester, UK
| | - Karina Lovell
- Mental Health Nursing, University of Manchester, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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15
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Hallett N, Dickens GL. De-escalation of aggressive behaviour in healthcare settings: Concept analysis. Int J Nurs Stud 2017; 75:10-20. [DOI: 10.1016/j.ijnurstu.2017.07.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/05/2017] [Accepted: 07/02/2017] [Indexed: 11/15/2022]
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16
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Bowers L, Cullen AE, Achilla E, Baker J, Khondoker M, Koeser L, Moylan L, Pettit S, Quirk A, Sethi F, Stewart D, McCrone P, Tulloch AD. 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. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05210] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundSeclusion (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.ObjectivesTo (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).DesignThe 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).ParticipantsPatients 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 measuresAggression, violence and cost (study 1), and utilisation, speed of use and attitudes to the full range of containment methods (study 2).ResultsPatients 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.LimitationsOfficial 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).ConclusionsClosing 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.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Len Bowers
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Alexis E Cullen
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Evanthia Achilla
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - John Baker
- School of Healthcare, University of Leeds, Leeds, UK
| | - Mizanur Khondoker
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Leonardo Koeser
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Lois Moylan
- Department of Nursing, Molloy College, Rockville, NY, USA
| | - Sophie Pettit
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Alan Quirk
- Royal College of Psychiatrists, London, UK
| | - Faisil Sethi
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Duncan Stewart
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Paul McCrone
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Alex D Tulloch
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
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