Safeguarding patients while implementing mechanical restraints: A qualitative study of nurses and ward staff's perceptions and assessment

A comprehensive examination of research instruments utilized for assessing the attitudes of healthcare professionals towards the use of restraints in mental healthcare: A systematic review

AIM

This systematic review aimed to identify, describe and evaluate questionnaires measuring health professionals' attitudes towards restraints in mental healthcare.

DESIGN

A systematic review was undertaken in accordance with the COSMIN protocol for systematic review and the relevant sections of the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

DATA SOURCES

OVID Medline, OVID nursing, Psychinfo, Embase and Cinahl were systematically searched from databases inception, with an initial search in December 2021 and updated in April 2022.

REVIEW METHODS

The inclusion criteria compromised articles reporting on self-reported instruments of attitudes or perceptions, development or validation of instruments and the evaluation of one or more measurement properties. Articles using multiple instruments in one study or not published in English were excluded. Two researchers independently extracted the data and appraised the methodological quality using the COSMIN guidelines and standards (consensus-based standards for the selection of health measurement instrument). A narrative synthesis without meta-analysis was performed. The systematic review was registered in PROSPERO Protocol ID CRD42022308818.

RESULTS

A total of 23 studies reporting ten instruments were included. The findings revealed a broad variation in the content of the questionnaires, the use of terms/constructs and the context in which the various instruments measure attitudes towards coercive measures. Many studies lacked sufficient details on report of psychometric properties. Finally, the results were not summarized and the evidence not GRADED.

CONCLUSIONS

There is a need for updated and adapted instruments with origins in theory and clear joint definitions such that attitudes towards coercive measures can be reliably assessed regarding the validity and reliability of instruments, which will be of importance to facilitate the use of instruments in research and clinical settings.

IMPACT

Reviews addressing surveys, self-reported attitudes towards restraints in mental healthcare and examination of psychometric properties seem limited. We highlight distinct complexity, psychometric limitations and broad variation in the context and content measuring attitudes towards coercive measures, and their various use of terms/constructs in the existing questionnaires. These findings contribute to further research regarding the development of questionnaires and the need of representing the concept well - carefully denoted by the indicators, likewise the importance of applying questionnaires with properly reported measurement properties in terms of validity and reliability to ensure the use in research and clinical settings.

Experiences of restrictive interventions in psychiatric health care from the perspectives of patients and health care professionals: Meta-synthesis of qualitative evidence

WHAT IS KNOWN ON THE SUBJECT

Following their experience, patients with physical restraints often experienced traumatic sensations. The experiences of healthcare professionals' (HCPs') are primarily concerned with moral distress or conflicts between loyalty to the treatment and oppression of the patient's freedom when implementing RIs.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

Improving the competency of HCPs can help establish therapeutic relationships rooted in compassionate care and facilitate appropriate assessments to determine whether and how often RIs are necessary. Furthermore, fostering an environment that guarantees patient safety and dignity, assuring a sufficient staffing ratio, and providing opportunities to share RI experiences can help improve the quality of care and build safe environments for RIs.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

Effective interaction between HCPs and patients, thorough patient assessment, and compassionate patient care may improve competency of HCPs intervene RIs procedures. Creating a safe therapeutic environment, including improvements to structural environments, increasing the staff-to-patient ratio, establishing organizational policies that guarantee staff debriefing, provide emotional support, provide appropriate training programs to HCPs to their coping skills during RIs also reduce the use of RIs and improve the quality of mental health care.

ABSTRACT

INTRODUCTION: Restrictive interventions (RIs) are used in psychiatric inpatient units for ensuring safety. However, few studies have comprehensively reviewed physical restraint and seclusion experiences from the perspectives of both patients and healthcare professionals' (HCPs'). This study aims to gain an in-depth understanding of the RI experiences of mental health inpatients and HCPs.

METHODS

A meta-synthesis was undertaken of qualitative studies exploring the RI experiences. Five electronic databases were searched and additional manual searches were performed for studies published within the last decade. Twelve articles were included, and a thematic analysis was conducted. The Critical Appraisal Skills Program (CASP) checklist was used to assess data quality.

FINDINGS

Two main subthemes were identified: 'Competency of HCPs' (three subthemes: interaction between patients and HCPs, assessment methods, and care) and 'systems' (three subthemes: environment, protocols with training, and debriefing), including both positive and negative experiences.

DISCUSSION

The Competency of HCPs and the ward environment are critical factors related to patients' unmet needs. Effective interactions between HCPs and patients, thorough patient assessments, and compassionate patient care are important elements of RI implementation.

CONCLUSION

An environment that guarantees safety and care with dignity, sufficient staffing ratios, and opportunities to share RI experiences may improve quality of care and create safe environments for RIs.

Is physical restraint unethical and illegal?: a qualitative analysis of Korean written judgments

BACKGROUND

Physical restraint (PR) is used to ensure the safety of care recipients. However, this causes an ethical dilemma between the autonomy and dignity of the recipients and the provision of effective treatment by health workers. This study aimed to analyze legal and ethical situations related to the use of PR using written judgments.

METHODS

This study uses a qualitative retrospective design. Qualitative content analysis was performed on South Korean written judgments. A total of 38 cases from 2015 to 2021 were categorized. The types of court decisions and ethical dilemma situations were examined according to the four principles of bioethics, and the courts' judgments were compared.

RESULTS

Written judgments related to PR were classified into three types according to the appropriateness of PR use, the presence or absence of duty of care, and legal negligence. Ethical dilemmas were categorized into three situations depending on whether the four principles of bioethics were followed. The courts' decisions regarding the ethical dilemmas differed depending on the situational factors before and after the use of PR and the conflicting conditions of the ethical principles.

CONCLUSIONS

Health workers should consider legal and ethical requirements when determining whether to use PR to provide the care recipient with the necessary treatment.

Ambulance personnel use of coercion and use of safety belts in Norway

BACKGROUND

Providing health care in a moving vehicle requires different considerations regarding safety than in other settings. Use of seatbelts are mandatory, and during ambulance transport patients are fastened to the stretcher with safety straps. However, patients who wriggle out of, or unfasten, their safety straps pose a threat to him/herself and escorting personnel in the ambulance compartment in case of an accident. To prevent harm, ambulance personnel sometimes restrain the patient or unfasten their own seatbelts to keep the patient safe on the stretcher. The prevalence of coercive measures, and the relationship between the use of mechanical restraints comparable to coercion and seatbelt use, are scarcely investigated. Use of coercion normally requires a specific statutory basis. However, coercive measures needed to ensure safety in a moving vehicle while providing healthcare is hardly discussed in the literature. The aim of this study is to explore the use of coercion in ambulance services, the use of safety belts among escorts in situations where they need to keep the patient calm during transportation, and to analyse the relationship between safety belt non-compliance and coercion in these situations.

METHODS

This is a retrospective, cross-sectional study using a self-administered, online survey aiming to investigate the use of coercion and use of seatbelts during ambulance transport. Approximately 3,400 ambulance personnel from all 18 Health Trusts in Norway were invited to participate between Oct 2021 and Nov 2022. Descriptive analyses were used to describe the sample and the prevalence of findings, while multiple linear regressions were used to investigate associations.

RESULTS

Altogether, 681 (20%) ambulance personnel completed the survey where 488 (72.4%) stated that they had used coercion during the last six months and 375 (55.7%) had experienced ambulance personnel or escorting personnel working with unfastened seatbelts during transport. The majority of respondents experienced coercion as being unpleasant and more negative feelings were associated with less use of seatbelts.

CONCLUSIONS

Coercion seems to be used by ambulance personnel frequently. For the study participants, keeping the patient securely fastened was prioritized above escorting personnel's traffic safety, despite feeling uncomfortable doing so. Because coercive measures have negative consequences for patients, is associated with negative feelings for health personnel, and is not discussed ethically and legally in relation to the prehospital context, there is an urgent need for more research on the topic, and for legal preparatory work to address the unique perspectives of the prehospital context in which traffic safety also is an important factor.

Humane and Comprehensive Management of Challenging Behaviour in Health and Social Care: Cross-Sectional Study Testing Newly Developed Instrument

BACKGROUND

Management of challenging behaviour causes victimization and violates the human rights of service users in psychiatric and long-term settings for people having mental health issues and learning disabilities. The purpose of the research was to develop and test an instrument for measuring humane behaviour management (HCMCB). The research was guided by the following questions: (1) What is the structure and content of the Human and Comprehensive management of Challenging Behaviour (HCMCB) instrument, (2) What are the psychometric properties of the HCMCB instrument, and (3) How do Finnish health and social care professionals evaluate their humane and comprehensive management of challenging behaviour?

METHODS

A cross-sectional study design and STROBE checklist were applied. A convenience sample of health and social care professionals (n = 233) studying at the University of Applied Sciences (n = 13) was recruited.

RESULTS

The EFA revealed a 14-factor structure and included a total of 63 items. The Cronbach's alpha values for factors varied from 0.535 to 0.939. The participants rated their individual competence higher than leadership and organizational culture.

CONCLUSIONS

HCMCB is a useful tool for evaluating competencies, leadership, and organizational practices in the context of challenging behaviour. HCMCB should be further tested in various international contexts involving challenging behaviour with large samples and longitudinal design.

Best practice recommendations on the application of seclusion and restraint in mental health services: An evidence, human rights and consensus-based approach

WHAT IS KNOWN ON THE SUBJECT?: Seclusion and restraint still regularly occur within inpatient mental health services. The Council of Europe requires the development of a policy on for instance age limits, techniques and time limits. However, they only define the outer limits of such a policy by indicating when rights are violated. Within these limits, many choices remain open. Staff and service managers lack clarity on safe and humane procedures. Research literature provides limited and contradictory insights on these matters. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The study resulted in 77 best practice recommendations on the practical application of restraint and seclusion as last resort intervention in inpatient youth and adult mental health services, including forensic facilities. To our knowledge, this is the first study in which the development of recommendations on this topic is not only based on scientific evidence, but also on an analysis of European human rights standards and consensus within and between expert-professionals and experts-by-experience. This approach allowed to develop for the first time recommendations on time limits, asking for second opinion, and registration of seclusion and restraint. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The 77 recommendations encourage staff to focus on teamwork, safety measures, humane treatment, age and time limits, asking for second opinion, observation, evaluation and registration when applying seclusion and restraint as last resort intervention. The implementation of the best practice recommendations is feasible provided that they are combined with a broad preventive approach and with collaboration between service managers, staff (educators) and experts-by-experience. Under these conditions, the recommendations will improve safety and humane treatment, and reduce harm to both service users and staff.

ABSTRACT

INTRODUCTION: Seclusion and restraint still regularly occur within inpatient mental health services. Professionals lack clarity on safe and humane procedures. Nevertheless, a detailed policy on for instance age limits, techniques and time limits is required.

AIM

We developed recommendations on the humane and safe application of seclusion, physical intervention and mechanical restraint in inpatient youth and adult mental health services, including forensic facilities.

METHOD

After developing a questionnaire based on a rapid scientific literature review and an analysis of human rights sources stemming from the Council of Europe, 60 expert-professionals and 18 experts-by-experience were consulted in Flanders (Belgium) through a Delphi-study.

RESULTS

After two rounds, all but one statement reached the consensus-level of 65% in both panels. The study resulted in 77 recommendations on teamwork, communication, materials and techniques, maximum duration, observation, evaluation, registration, second opinion and age limits.

DISCUSSION

Combining an evidence, human rights and consensus-based approach allowed for the first time to develop recommendations on time limits, asking for second opinion and registration.

IMPLICATIONS FOR PRACTICE

When combined with a preventive approach and collaboration between service managers, staff (educators) and experts-by-experience, the recommendations will improve safety and humane treatment, and reduce harm to service users and staff.