Mental health inpatients' and staff members' suggestions for reducing physical restraint: A qualitative study

Reducing seclusion and restraint in an acute adolescent psychiatric ward: A feasibility study

WHAT IS KNOWN ON THE SUBJECT

Restraining and secluding health consumers for safety reasons continue to be used in psychiatric inpatient facilities even though they have no therapeutic value and have negative effects on consumers, families and staff. Six Core Strategies (6CS) for reducing seclusion and restraint have been developed to address this problem but there are very few effectiveness studies in inpatient adolescent psychiatric facilities.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

We used a mixed methods approach to evaluate the implementation of 6CS in an adolescent psychiatric facility. The implementation was successful. It eliminated the use of seclusion, substantially reduced the use of restraints and significantly reduced staff absenteeism. Using thematic analysis on feedback surveys, we identified five dominant themes that described consumers' and carers' experiences during their stay at the facility: communication, service delivery, flexibility, consistency and internal feeling states.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

This study provides support for the feasibility of a comprehensive and broad-based intervention program such as 6CS to reduce seclusion and restraint practices in inpatient mental health facilities. This study also demonstrates the value of using surveys to gather consumer and carer feedback and improve outcomes for service users.

ABSTRACT

Introduction Seclusion and restraint practices are routinely used in psychiatric facilities but are controversial for ethical, legal and safety reasons, and can cause significant harm to consumers, staff and organisations. Six Core Strategies (6CS) for reducing seclusion and restraint were developed to address this problem but very few studies have examined their effectiveness in adolescent settings. Aim/Question To evaluate the implementation of 6CS in an adolescent inpatient psychiatric facility. Method We retrieved archival data from an acute adolescent psychiatric ward that implemented the 6CS. Using a mixed methods approach, we evaluated outcomes on the use of seclusion and restraint, nursing staff sick leave and feedback surveys. Results Findings showed an elimination of seclusion, and a significant reduction in restraint use and staff absenteeism in the 12 months after project implementation. Thematic analysis of feedback survey responses identified communication, service delivery, flexibility, consistency and internal feeling states as dominant themes in consumers' and carers' experience on the unit. Discussion The 6CS is feasible and may be effective in reducing seclusion and restraint, which in turn may have a positive impact on staff wellbeing. Implications for Practice Implementation of the 6CS with executive support, combined with staff and programmatic changes at a local level is recommended.

The experience of healthcare professionals implementing recovery-oriented practice in mental health inpatient units: A qualitative evidence synthesis

WHAT IS KNOWN ON THE SUBJECT?: The principles of personal recovery are primarily applied in outpatient and community settings as these settings provide continuity of care and recovery-based community programs supporting consumers' recovery journey. A range of healthcare professionals are involved in the care of people within mental health in-patient units, including nurses, psychiatrists, psychologists, occupational therapists and social workers. The integration of recovery-oriented care in mental health inpatient units may be impaired by a lack of confidence among mental health professionals. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Developing hope and a safe place is an integral part of recovery-oriented practice within mental health inpatient units. Instilling connectedness is a relevant recovery principle; however, there may be greater barriers in mental health settings which traditionally prioritise safety and risk mitigation practices to prevent perceived harmful behaviours. Staff workload and inadequate understanding of recovery concepts present challenges to promoting recovery-oriented care in everyday practice. Using strength-based practice is critical in promoting a safe space for consumers by providing psychosocial interventions and person-centred care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The provision of recovery-oriented practice requires adopting a collaborative approach that places a strong emphasis on the involvement of consumers and their families. Empowering mental health professionals to believe that recovery-oriented practice is possible in mental health inpatient units is crucial. Mental health professionals need to create a safe environment and positive relationships through respect and empathy for consumers and their family members. ABSTRACT: Introduction Recovery-oriented practice underpins an individual's personal recovery. Mental health nurses are required to adopt a recovery-oriented approach. Globally, a paucity of literature exists on mental health professionals' experience of recovery-oriented practice in mental health inpatient units. Aim The aim of this synthesis was to explore the experiences of healthcare professionals regarding recovery-oriented care in mental health inpatient units by appraising and synthesising existing qualitative research. Method Three databases, including MEDLINE, PsycINFO and CINAHL were searched between 2000 and 2021. Data were extracted and synthesised using thematic integrative analysis. The quality of included studies was assessed with the CASP Critical Appraisal Checklist. Results Ten qualitative research projects met the inclusion criteria. Four themes were identified (i) developing a safe and hopeful space, (ii) promoting a healing space, (iii) instilling connectedness and (iv) challenges to realising recovery-oriented care. Discussion Mental healthcare professionals perceived the principles of recovery-oriented care to be positive and include: therapeutic space, holistic care and person-centred care. Nevertheless, findings revealed limited knowledge and uncertainty of the recovery concept to be key barriers that may hinder implementation into practice. Implications for Practice Recovery-oriented practice must underpin consumer and family engagement, treatment choices and continuity of care to facilitate consumer's personal recovery.

Use of coercion in mental healthcare services in Nigeria: Service providers' perspective

BACKGROUND

There is increasing advocacy to reduce coercive practices in mental healthcare. Little research has been done on the topic in developing countries.

AIMS

To explore what mental health professionals in Nigeria think about coercion, why it is used, and what contextual factors influence its use in mental healthcare services.

METHODS

Semi-structured interviews were carried out with 16 doctors and 14 nurses from two psychiatric hospitals in two regions of Nigeria. The audio-recorded interviews were analyzed thematically with the aid of MAXQDA software.

RESULTS

Three broad categories relating to the perception of, reasons for, and barriers/facilitators to the use of coercion were derived. Coercion was viewed as being for the best interests of patients, a means to an end, and effective for achieving desired outcomes. Safety was both a reason to use a coercive measure and a deterrent to using specific coercive measures thought to be unsafe. The socio-cultural context, obsolete mental health legislation, staff shortages, and attitudes were factors influencing the use of coercion in mental healthcare.

CONCLUSION

Coercion was perceived to be ultimately beneficial in mental health practice. There is need for a new mental health legislation and more resources for mental health care in Nigeria to address the problem of coercion.

Physical Restraint Experience of Patients with Mental Disorders in Mainland China: A Qualitative Study

Introduction

The use of physical restraint (PR) is considered a controversial practice and research in Western countries has demonstrated negative physical and psychological consequences for patients, as well as staff, family members/carers, organisations and society as a whole. However, there are few research reports on restraint experiences of patients with mental disorders in non-Western countries, especially in mainland China.

Aim

This study aims to explore the subjective experiences and perceptions of patients with psychiatric disorders who have experienced PR in mainland China.

Methods

Semi-structured interviews were conducted with 8 inpatients with mental disorders in convalescence at a specialized mental health hospital in Shanghai. Interviews were recorded on audiotape and transcribed verbatim. Transcripts were analyzed using thematic analysis.

Results

Five themes emerged: "perception and understanding of PR", "response to PR", "negative physical and psychological experiences", "unmet care needs during PR" and "changes after PR", which together characterize patients' perceptions, experiences, feelings, and needs in PR.

Conclusion

The use of PR involves ethical issues and brings negative experiences to patients with mental disorders that cannot be ignored and should be used as a last resort. Different patients have different attitudes and reactions to PR. During PR, patients' physical and psychological needs are not adequately met. Medical staff should give more attention to patients in PR, meet their physical and psychological needs, and actively seek PR alternatives and reduction options based on evidence-based resources on restraint reduction available in the West and the national context and culture of China.

Investigation of the Consumer Perspective on Leisure in Mental Health Inpatient Units

This study aimed to explore the barriers to engagement in activity and consumer satisfaction in inpatient settings. Participants were current inpatient consumers and completed an online anonymous survey. This included the Mental Health Satisfaction Improvement Program (MHSIP), Leisure Boredom Scale (LBS), and the Checklist of Leisure Interests and Participation (CLIP). A total of 57 participants partially completed the survey with 41 completed responses. Participants reported several barriers to engagement, including lack of staff, limited social engagement, limited range of activity, and a lack of resources. Most participants reported to be either "very satisfied" (24.24%) or "somewhat satisfied" (36.36%) with the level of activity offered. Participants reported to be bored due to a limited occupational range offered in the mental health inpatient unit. Participants identified the need for assistance in the facilitation of activity.

Physical restraints applied to people diagnosed with dementia in home care from the perceptions of family caregivers: A qualitative study in China

WHAT IS KNOWN ON THE SUBJECT?: Physical restraint is widely used in the elderly at home, and cognitive impairment is an important risk factor. Family caregivers of people with dementia are the main decision makers and implementers of physical restraint at home. Most people with dementia in China receive home care, and family caregivers face enormous care and moral pressures influenced by Confucian culture. Current research on physical restraints focuses on quantitative analysis of its prevalence and reasons within the institutions. There is little research on how family caregivers perceive physical restraints in home care context, especially under Chinese culture. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Many family caregivers face approach - avoidance conflict and moral dilemmas when making decisions to restrain, and they make difficult choices in these dilemmas. In China, family caregivers are influenced by many unique factors, including traditional Confucian culture, family affection, and rural home environment. Inadequate laws and policies provide the ground for abuse of physical restraints, and family caregivers rarely consider legal and policy restrictions when using physical restraints. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: With limited medical resources, nurse-led dementia management is the hope to reduce physical restraints in home. Mental health nurses need to assess for the appropriateness of physical restraints associated with psychiatric symptoms in people with dementia. At both organizational and community levels, improving effective communication and relationships between professionals and family caregivers are important to address. Improvements in this context require education and time for staff to develop skills and experience which is necessary to provide family caregivers with ongoing information and psychological support within their communities. Considering Confucian culture will be of value for mental health nurses working in other countries where there are Chinese communities to better understand perceptions of family caregivers.

ABSTRACT

INTRODUCTION: The use of physical restraints is a common practice in home care. Family caregivers face care-related and moral pressures due to the influence of Confucian culture in China. The use of physical restraints in the Chinese cultural environment may differ from the use of such restraints in other cultures.

SCIENTIFIC RATIONALE

Current research on physical restraints focuses on quantitative analysis of its prevalence and reasons within the institutions. However, there is little research on how family caregivers perceive physical restraints in home care context, especially under Chinese culture.

AIM

To explore the perceptions of family caregivers on physical restraints in people diagnosed with dementia receiving home care.

METHOD

A descriptive, qualitative study of Chinese family caregivers of people diagnosed with dementia in home care. Framework method analysis was adopted using the multilevel socio-ecological model.

RESULTS

Beliefs about benefit lead to a dilemma for family caregivers. Cherishing family's affection encourages caregivers to reduce physical restraints, but lack of help from family members, professionals and the community forces them to restrain their loved ones.

DISCUSSION

Future research should explore the complex issue of culturally specific physical restraints decisions.

IMPLICATIONS FOR PRACTICE

Mental health nurses must receive education regarding the negative outcomes of the use of physical restraints for family members of people diagnosed with dementia. A more liberal approach to mental health and relevant legislation, which is an emerging global phenomenon that is currently in an early phase of development in China, grants human rights to people diagnosed with dementia. Effective communication and relationships between professionals and family caregivers can contribute to the establishment of a dementia-friendly community in China.

Zero Tolerance for Coercion? Historical, Cultural and Organisational Contexts for Effective Implementation of Coercion-Free Mental Health Services around the World

Coercion of service users/patients when receiving care and treatment has been a serious dilemma for mental health services since at least the 18th century, and the debate about how best to minimise or even eradicate compulsion remains intense. Coercion is now, once again and rightly, at the top of the international policy agenda and the COST Action 'FOSTREN' is one example of a renewed commitment by service user advocates, practitioners and researchers to move forward in seriously addressing this problem. The focus of service improvement efforts has moved from pure innovation to practical implementation of effective interventions based on an understanding of the historical, cultural and political realities in which mental health services operate. These realities and their impact on the potential for change vary between countries across Europe and beyond. This article provides a novel overview by focusing on the historical, cultural and political contexts which relate to successful implementation primarily in Europe, North America and Australasia so that policy and practice in these and other regions can be adopted with an awareness of these potentially relevant factors. It also outlines some key aspects of current knowledge about the leading coercion-reduction interventions which might be considered when redesigning mental health services.

A qualitative integrative analysis of service users' and service providers' perspectives on ways to reduce coercion in mental health care

PURPOSE

The movement to develop and implement non-coercive alternatives in the provision of mental health care is gaining momentum globally. To strengthen the basis of potential interventions that will be contextually relevant, and to complement the body of literature which is largely from high-income settings, the current study sought to explore the suggestions of service users and providers in Nigeria on how to reduce the use of coercive measures in mental health settings.

METHODS

Semi-structured interviews with 30 mental health professionals and four focus group discussions among 30 service users from two psychiatric hospitals in Nigeria were conducted. The data were analyzed thematically with the aid of MAXQDA.

RESULTS

The suggestions proposed by service users and mental health professionals were within the broad themes of communication, policies and legislation, and increased resources. Service users felt that improved communication, home consultations, non-legal advocates and clear rules and legislation would reduce the use of coercion, while service providers suggested increased public mental health literacy, better interpersonal relationships with patients, increased resources for mental health care, more research on the topic and regulation of coercive measures.

CONCLUSION

Many of the suggestions from this study reinforce strategies already in place to decrease coercion in other settings. However, additional recommendations that are relevant to the study setting, such as enhancing public mental health literacy, mental health legislation reform and increasing access to mental health services, deserve further consideration.

Healthcare staff's experiences of using manual physical restraint: A meta-synthesis review

Manual restraint is a hands-on type of physical restraint used to prevent harm to service users and staff, and to administer necessary treatments. This article reports on a review and meta-synthesis of the qualitative literature on healthcare staff's experiences of using manual restraint. Three electronic databases (CINAHL Complete, MEDLINE, and PsycINFO) were systematically searched, and 19 studies were included. Thematic synthesis was used to synthesize the findings. The Critical Appraisal Skills Programme (CASP) checklist was used to appraise study quality. The synthesis generated one overarching interpretive theme, "unpleasant but necessary," and five subthemes: "maintaining safety triumphs all," "emotional distress," "significance of coping," "feeling conflicted," and "depletion." Seven studies indicated that, from staff perspectives, manual restraint was not always used as a last resort. Healthcare staff experience manual restraint as a psychologically and physically unpleasant practice, yet paradoxically deem its use to be sometimes necessary to keep themselves and service users safe from harm. The findings indicate a need for healthcare staff support, post-restraint debriefing meetings with service users, and the implementation of manual restraint minimization programs in healthcare settings.

Prevalence, Risk Factors and Outcomes Associated with Physical Restraint in Acute Medical Inpatients over 4 Years-A Retrospective Cohort Study

BACKGROUND

Physical restraints are frequently used in acute care hospitals. Their application is associated with negative outcomes, while their intended preventive effect is debated.

OBJECTIVES

To determine the prevalence of physical restraints and associated outcomes on medical wards in a tertiary care hospital.

METHODS

Retrospective cohort study (January 2018 to December 2021). We included all adult medical in-patients and excluded patients with admission to the intensive care unit, short stays (length of stay (LOS) < 48 h), and patients declining informed consent.

RESULTS

Of 11,979 admissions, the prevalence of patients with at least one restraint was 6.4% (n = 772). Sensor mats were used most frequently (73.0%, n = 666), followed by blanket restrictions (14.5%, n = 132), bedrails (8.8%, n = 80) and belts (3.7%, n = 34). On average, restraints were applied 19 h (standard deviation (SD) ± 161) before a fall. Average restraint duration was 42 h (SD ± 57). Patients with a restraint had longer LOS 8 days (IQR 5-14) vs. 5 days (IQR 3-9). Median nurses' time expenditure was 309 h (IQR 242-402) vs. 182 h (IQR 136-243) for non-restrained patients. Patients with restraints fell more often (22.5% vs. 2.7%) and were more likely to die (13.3% vs. 5.1%). These differences persisted after adjusting a regression model for important clinical confounders. We saw a decline in the duration of restraints over the years, but no variation between wards.

CONCLUSION

Approximately 6% of medical patients, mostly older and severely ill, were affected by restraint use. For the first time, we report data over 4 years up to ward-level granularity.

Proactive Detection (PROTECT) and Safety Planning to Shorten Emergency Department Stays for Psychiatric Patients

OBJECTIVE

A literature gap exists for interventions to decrease average length of stay (ALOS) for patients with psychiatric presentations at the emergency department (ED). Long ALOSs are often related to sequential assessments of patients with high suicide risk or patients awaiting an inpatient bed. Safety planning may provide opportunities for diverting patients to the community and for reducing ED ALOS. This study reports on the impact of a safety-planning approach based on the PROTECT (proactive detection) framework for suicide prevention.

METHODS

A complex intervention (comprising leadership, governance, and innovation) was instrumental in embedding a new clinical culture of proactive detection and positive risk management through safety planning at Princess Alexandra Hospital in Brisbane, Queensland, Australia. Practice as usual continued at a comparator nonintervention site (NIS). In total, 24,515 psychiatric presentations over 24 months were grouped into monthly averages for key outcomes, providing a sample size of 24 at each site. A difference-in-differences analysis across sites, preintervention (January-November 2019) and postimplementation (December 2019-December 2020), was used to estimate the intervention's impact.

RESULTS

ED ALOS for psychiatric presentations, patients with an ALOS >12 hours, patients with an ALOS >24 hours, and inpatient psychiatric admissions decreased significantly compared with NIS (p<0.01) pre- and postimplementation of the safety-planning intervention.

CONCLUSIONS

Embedding a recovery-oriented culture of safety significantly reduced ED ALOS for psychiatric evaluations. Leadership, governance, and innovative practices that shift the focus of assessment and care from a mindset of risk prediction to one of prevention through collaborative safety planning as outlined in the PROTECT framework may have far-reaching benefits for patient care.

Safewards: An integrative review of the literature within inpatient and forensic mental health units

Mental health inpatient units are complex and challenging environments for care and treatment. Two imperatives in these settings are to minimize restrictive practices such as seclusion and restraint and to provide recovery-oriented care. Safewards is a model and a set of ten interventions aiming to improve safety by understanding the relationship between conflict and containment as a means of reducing restrictive practices. To date, the research into Safewards has largely focused on its impact on measures of restrictive practices with limited exploration of consumer perspectives. There is a need to review the current knowledge and understanding around Safewards and its impact on consumer safety. This paper describes a mixed-methods integrative literature review of Safewards within inpatient and forensic mental health units. The aim of this review was to synthesize the current knowledge and understanding about Safewards in terms of its implementation, acceptability, effectiveness and how it meets the needs of consumers. A systematic database search using Medline, CINAHL, Embase and PsychInfo databases was followed by screening and data extraction of findings from 19 articles. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of empirical articles, and the Johanna Brigg's Institute (JBI's) Narrative, Opinion, Text-Assessment and Review Instrument (NOTARI) was used to undertake a critical appraisal of discussion articles. A constant comparative approach was taken to analysing the data and six key categories were identified: training, implementation strategy, staff acceptability, fidelity, effectiveness and consumer perspectives. The success of implementing Safewards was variously determined by a measured reduction of restrictive practices and conflict events, high fidelity and staff acceptability. The results highlighted that Safewards can be effective in reducing containment and conflict within inpatient mental health and forensic mental health units, although this outcome varied across the literature. This review also revealed the limitations of fidelity measures and the importance of involving staff in the implementation. A major gap in the literature to date is the lack of consumer perspectives on the Safewards model, with only two papers to date focusing on the consumers point of view. This is an important area that requires more research to align the Safewards model with the consumer experience and improved recovery orientation.

Current State of Research on Coercion in Mental Health: Umbrella Review Protocol

In recent years, international organizations, professionals, and representatives of mental health service users have expressed the need to regulate, limit, and even eliminate coercive measures in psychiatric treatment. The main objective of the current review is to provide a comprehensive synthesis of existing evidence on coercion in mental health care through a protocol for an umbrella review of systematic reviews. This protocol was designed according to the Joanna Briggs Institute guide for methodological development, conduct, and reporting of umbrella reviews. To minimize bias in the process, two independent reviewers selected the studies to be included, extracted, and synthesized; analyzed the data; and assessed risk of bias of each review. The review protocol was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guidelines. This review offers a comprehensive compilation of systematic reviews on coercion developed to date. Coercion causes adverse physical and psychological effects and is an emotional stressor for individuals with psychiatric diagnoses and health care workers. Characterization of coercion across care settings, its impact on clinical outcomes, the perception of those involved, and how coercion could be reduced will also be discussed. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

Nurses' beliefs, attitudes, and opinions regarding a smoking ban in a psychiatric hospital

PURPOSE

This study aims to identify the beliefs, attitudes, and opinions of nursing professionals associated with tobacco smoking and its prohibition in a psychiatric hospital in Brazil.

METHODS

Using a cross-sectional epidemiologic study, a total of 73 nursing professionals in a smoke-free psychiatric hospital were interviewed. The Varimax Rotation and the Fisher's exact test at a 5% significance level were used to analyze the responses.

FINDINGS

Most nursing professionals reported observations of patients becoming calmer after smoking (n = 59, 80.8%) and tobacco withdrawal worsening patients' mental health symptoms, suggesting agreement among professionals that some psychiatric patients need to smoke tobacco. Most respondents stated that patients with mental health disorders have more difficulty with smoking cessation (79.4%) and are less interested in quitting smoking than those without disorders (95.9%). While one-third mentioned having used cigarettes as a reward or bribe, the majority (83.6%) was in favor of continuing the smoking ban, with more support observed from those working on a night shift and those who worked in the public psychiatric wards. Over 71% noted improvements in their health after the smoking ban.

CONCLUSION

The nursing professionals were surprised by the effectiveness of the smoking ban and highlighted the improvement in the hospital environment after its implementation.

CLINICAL RELEVANCE

As trusted healthcare professionals, nurses are essential in the fight against smoking and can contribute to awareness promotion, supporting patients during nicotine withdrawal, and decision-making processes for health policies.

Risk factors associated with use of coercive practices in adult mental health inpatients: A systematic review

WHAT IS KNOWN ON THE SUBJECT?: Coercive practices such as restraint (physically holding a person) or seclusion (containing a person in locked room) are frequently used in mental health care. How often and which specific practices are used is not consistent across different healthcare systems, hospitals or wards. Internationally, there is agreement on the need to monitor and reduce the use of coercive practices. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The reviewed evidence suggests a number of different factors affect a person's risk of experiencing coercive practices, while admitted to a mental health ward. However, there is currently not enough high-quality research evidence to say which factors are most important or how they work to influence the likelihood of a person experiencing coercive practice. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: When carrying out risk assessments, mental health professionals must take into account that a number of different factors are important and explore these with the patient. Care plans aimed at minimizing the use of coercive practices, such as restraint, must be personalized and developed with the individual. ABSTRACT: Introduction Coercive practices, such as physical restraint and seclusion, are a common feature of all mental healthcare systems. However, there is considerable variation in their use, concern about their iatrogenic potential and agreement internationally on the need to monitor and reduce their use. Aims To examine the evidence concerning risk factors associated with use of coercive practices in adults admitted to inpatient psychiatric services. Method A systematic review, consistent with PRIMSA guidelines, of four databases (PsychINFO, Medline, CINHAL and Embase). Peer-reviewed, English language articles from database inception to February 2020 were included. Methodological quality was assessed using the Quality Assessment Tool for Quantitative Studies. Results Twenty studies met inclusion criteria. Risk factors examined in the studies organized around four categories: patient socio-demographic; patient clinical; staff; and organizational factors. Overall, methodological quality of papers was deemed weak, and there was insufficient evidence to support any singular risk factor. Discussion The reviewed evidence suggests risk of coercive practice in inpatient mental health settings is multifactorial. Further research to standardize concept definitions and elucidate the mechanisms behind variance in use is required. Implications for Practice Assessment of patients at risk of coercive practice must take a multifactorial approach.

Relationship between nurses' use of verbal de-escalation and mechanical restraint in acute inpatient mental health care: a retrospective study

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.

How may cultural and political ideals cause moral distress in acute psychiatry? A qualitative study

BACKGROUND

There is growing public criticism of the use of restraints or coercion. Demands for strengthened patient participation and prevention of coercive measures in mental health care has become a priority for care professionals, researchers, and policymakers in Norway, as in many other countries. We have studied in what ways this current ideal of reducing the use of restraints or coercion and attempting to practice in a least restrictive manner may raise morals issues and create experiences of moral distress in nurses working in acute psychiatric contexts.

METHODS

Qualitative interview study, individual and focus group interviews, with altogether 30 nurses working in acute psychiatric wards in two mental health hospitals in Norway. Interviews were recorded and transcribed. A thematic analytic approach was chosen.

RESULTS

While nurses sense a strong expectation to minimise the use of restraints/coercion, patients on acute psychiatric wards are being increasingly ill with a greater tendency to violence. This creates moral doubt and dilemmas regarding how much nurses should endure on their own and their patients' behalf and may expose patients and healthcare personnel to greater risk of violence. Nurses worry that new legislation and ideals may prevent acutely mentally ill and vulnerable patients from receiving the treatment they need as well as their ability to create a psychological safe climate on the ward. Furthermore, persuading the patient to stay on the ward can cause guilt and uneasiness. Inadequate resources function as external constraints that may frustrate nurses from realising the treatment ideals set before them.

CONCLUSIONS

Mental health nurses working in acute psychiatric care are involved in a complex interplay between political and professional ideals to reduce the use of coercion while being responsible for the safety of both patients and staff as well as creating a therapeutic atmosphere. External constraints like inadequate resources may furthermore hinder the healthcare workers/nurses from realising the treatment ideals set before them. Caught in the middle nurses may experience moral distress that may lead to physical discomfort, uneasiness and feelings of guilt, shame, and defeat. Pressure on nurses and care providers to reduce or eliminate the use of coercion and reduction of health care spending are incompatible demands.

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.

'You get this conflict between you as a person and you in your role…that changes you': A thematic analysis of how inpatient psychiatric healthcare staff in the UK experience restraint, seclusion, and other restrictive practices

A high proportion of psychiatric inpatients experience Restrictive Practice (RP) during admission. Numerous reports have highlighted adverse effects on patients and staff. However, qualitative research focussed on experience, impact, and coping mechanisms of healthcare staff in the UK is limited. Therefore, this study explored psychiatric healthcare staff experience of RP on inpatient wards in the UK. Eight semi-structured, audio-recorded interviews, of ~60 min, were conducted via telephone/Skype and transcribed verbatim. A critical realist epistemology was used to thematically analyse data. Three themes were identified: the coexistence of accountability, power and subjection; impacts on the individual and professional relationships, and coping with difficult experiences and emotions. Restrictive practice can negatively affect staff experience, working relationships, and wellbeing. Opportunities for support could mediate adverse effects. Future research could further explore coping mechanisms and organizational factors contributing to negative staff experiences.

A regional multicomponent intervention for mechanical restraint reduction in acute psychiatric wards

WHAT IS KNOWN ON THE SUBJECT?: A relevant number of restraint prevention programmes have been developed internationally. In Spain, there is no harmonized policy to prevent the use of restraint. More studies are necessary to establish which programmes and components are necessary to prevent restraint. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: There was a significant decreasing trend in the total number of mechanical restraint hours during the implementation of the intervention. There was no significant decreasing trend in the number of mechanical restraint episodes. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Interventions at a regional level aimed at preventing mechanical restraint are feasible in the Spanish context. All components of the Six Core Strategies could be necessary to prevent episodes of mechanical restraint. ABSTRACT: Introduction Mechanical restraint (MR) is used in many countries, including Spain, where non-harmonized policies between autonomous communities exist. There is a lack of research about interventions at regional levels to reduce their use. Aim To analyse data on key outcomes during the implementation of a multicomponent intervention in Andalusia (Spain) to reduce the use of MR. Method Episodes in a period of 30 months in all wards (N = 20) were analysed. The intervention consisted of five strategies: (a) leadership, (b) analysis of the situation, (c) awareness training for the heads of the wards, (d) unified record of MR and (e) staff training. We analysed the monthly trend of restraint hours and restraint episodes/1,000 bed days using segmented regression. Results There were 206.32 restraint hours and 12.96 restraint episodes/1,000 bed days during the study period. A significant decreasing trend was observed in restraint hours (-1.79%, p < .001), but not in the number of restraint episodes (-0.45%; p = .149). Discussion The results coincide with other international studies; however, studies with better designs are required to evaluate the effectiveness of the intervention. Implications for Practice Interventions at a regional level aimed at preventing MR are feasible in the Spanish context.

Mental health nurses experience of the introduction and practice of the Safewards model: a qualitative descriptive study

BACKGROUND

A lack of safety experienced by patients and staff in acute psychiatric units is a major concern and containment methods used to manage conflict have the potential to cause harm and upset to both staff and patients. To ensure safety for all, it is highly desirable to reduce levels of conflict and containment and the Safewards model is an evidence-based model aimed at reducing conflict and containment rates by improving nurse-patient relationships and safety.

METHODS

The aim of this study was to explore mental health nurses' experience of the introduction and practice of three Safewards interventions; reassurance, soft words and discharge messages. A qualitative descriptive research design utilising a purposive sample (n = 21) of registered psychiatric nurses (n = 16) and managers (n = 5) in an acute psychiatric unit in Ireland. Following a 12-week implementation of Safewards, three focus groups were conducted, two with nursing staff and one with nurse managers. Data were analysed using Braun and Clarke thematic analysis framework which supported the identification of four themes: introducing Safewards, challenges of Safewards, impact of Safewards and working towards success.

RESULTS

The findings indicate that the process of implementation was inadequate in the training and education of staff, and that poor support from management led to poor staff adherence and acceptance of the Safewards interventions. The reported impact of Safewards on nursing practice and patient experience were mixed. Overall, engagement and implementation under the right conditions are essential for success and while some participants perceived that the interventions already existed in practice, participants agreed Safewards enhanced their communication skills and relationships with patients.

CONCLUSION

The implementation of Safewards requires effective leadership and support from management, mandatory training for all staff, and the involvement of staff and patients during implementation. Future research should focus on the training and education required for successful implementation of Safewards and explore the impact of Safewards on nursing practice and patient experience.

Taser use on individuals experiencing mental distress: An integrative literature review

WHAT IS KNOWN ABOUT THE SUBJECT?: People experiencing mental distress have a high rate of contact with police in community crisis events. Police use a continuum of responses when managing situations involving agitation, aggression and behavioural problems. People experiencing mental distress have been subjected to Tasers as part of the police response. Following a number of deaths and numerous reports of injuries, concerns have been raised about the safety of Tasers. WHAT THIS PAPER ADDS?: Police use of Tasers in mental health crises is relatively common. Tasers are used in a range of settings including public places, private residences and healthcare facilities. People experiencing mental distress may be subjected to more use of Tasers than the general population. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health professionals need to work with police towards greater understanding of the needs of people experiencing mental distress and to promote the use of non-coercive interventions in mental health crisis events. Mental health researchers need to explore the qualitative experiences of people who are Tasered, to provide an evidence base for Taser use with people experiencing mental distress. ABSTRACT: Introduction Conducted electrical weapons, or "Tasers," are currently used by over 15,000 law enforcement and military agencies worldwide. There are concerns regarding the effectiveness, potential for harm and overuse with people experiencing mental distress. Aim To explore the literature about police use of Tasers with people experiencing mental distress. Method An integrative review was undertaken, and qualitative and quantitative analytical approaches were used. Results Thirty-one studies were included. Of all recorded usage, overall prevalence of Taser use on people experiencing mental distress was 28%. This population appears to experience higher Taser usage than the general population. Discussion There are substantial gaps in the research literature particularly with respect to the decision-making processes involved in deploying Tasers on this population and the physical and psychological consequences of Taser use in this context. Implications for practice Police use of Tasers in mental health crises is relatively common and occurs in a variety of environments including mental health settings. Mental health professionals need to work with police towards greater understanding of the needs of people with mental illness and to promote the use of non-coercive interventions in mental health crisis events.

Effectiveness of CRSCE-Based De-escalation Training on Reducing Physical Restraint in Psychiatric Hospitals: A Cluster Randomized Controlled Trial

Background: The use of physical restraint (PR) causes clinical and ethical issues; great efforts are being made to reduce the use of PR in psychiatric hospitals globally. Aim: This study aimed to examine the effectiveness of CRSCE-based de-escalation training on reducing PR in psychiatric hospitals. Method: The proposed study adopted cluster randomized controlled trial design. Twelve wards of a psychiatric hospital were randomly allocated to experimental group (n = 6) and control group (n = 6). Wards of control group were assigned to routine training regarding PR; wards of experimental group underwent the same routine training while additionally received CRSCE-based de-escalation training. Before and after CRSCE-based de-escalation training, the frequency of and the duration of PR, and the numbers and level of unexpected events caused by PR, were recorded. Results: After CRSCE-based de-escalation training, the frequency (inpatients and patients admitted within 24 h) of and the duration of PR of experimental group, showed a descending trend and were significantly lower than those of control group (P < 0.01); compared to control group, the numbers of unexpected events (level II and level III) and injury caused by PR of experimental group had been markedly reduced (P < 0.05). Conclusions: CRSCE-based de-escalation training would be useful to reduce the use of PR and the unexpected event caused by PR in psychiatric hospitals. The modules of CRSCE-based de-escalation training can be adopted for future intervention minimizing clinical use of PR. Clinical Trial Registration: This study was registered at Chinese Clinical Trial Registry (Registration Number: ChiCTR1900022211).

Using Empathetic CAre and REsponse (ECARE) in improving empathy and confidence among nursing and medical students when managing dangerous, aggressive and violent patients in the clinical setting

BACKGROUND

The use of physical restraint to curtail dangerous or extremely disruptive behaviours in patients has been an established practice to help ensuring safety in healthcare providers' work environment. However, many have deemed it unnecessary and overused with reported negligence on patients' basic needs during its implementation. Studies have shown that having empathy and non-judgmental attitudes are vital in reducing and eliminating the use of restraint.

OBJECTIVES

To explore whether experiential learning will improve empathy and confidence, among nursing and medical students when managing dangerous, aggressive, and violent patients.

DESIGN

A pre- and post-test, same group quasi-experimental design was used to explore the effectiveness of using the Empathetic CAre and REsponse (ECARE), an experiential learning session to equip nursing and medical students on managing dangerous, aggressive, and violent patients. Outcome measures include students' confidence when using verbal de-escalation, physical and chemical restraint techniques. Empathy scores were also compared.

SETTINGS

A University offering both medical and nursing program from undergraduate to postgraduate level.

PARTICIPANTS

249 nursing and 50 medical students undergoing the mental health nursing module in Year 2 of their nursing program and psychiatry rotation in Year 3 of their medical education.

RESULTS

Results showed that, for both student populations, the empathy and confidence scores significantly improved after attending ECARE. ANCOVA conducted on the post-intervention Jefferson empathy score between the populations with an adjusted baseline score revealed a statistically significant adjusted mean difference between them.

CONCLUSIONS

This study demonstrated that experiential learning could improve the learners' empathy through the integration of hands-on learning. This in turn could enhance future healthcare professionals' care quality. Experiential learning opportunities should be incorporated into existing pedagogies as this helps to improve students' confidence in managing dangerous, aggressive and violent patients, reducing the use of physical restraint, thereby enhancing the quality of patient care.

Identification of risk factors for involuntary psychiatric hospitalization: using environmental socioeconomic data and methods of machine learning to improve prediction

BACKGROUND

The purpose of this study was to identify factors associated with a high risk of involuntary psychiatric in-patient hospitalization both on the individual level and on the level of mental health services and the socioeconomic environment that patients live in.

METHODS

The present study expands on a previous analysis of the health records of 5764 cases admitted as in-patients in the four psychiatric hospitals of the Metropolitan City of Cologne, Germany, in the year 2011 (1773 cases treated under the Mental Health Act and 3991 cases treated voluntarily). Our previous analysis had included medical, sociodemographic and socioeconomic data of every case and used a machine learning-based prediction model employing chi-squared automatic interaction detection (CHAID). Our current analysis attempts to improve the previous one through (1) optimizing the machine learning procedures (use of a different type of decision-tree prediction model (Classification and Regression Trees (CART) and application of hyperparameter tuning (HT)), and (2) the addition of patients' environmental socioeconomic data (ESED) to the data set.

RESULTS

Compared to our previous analysis, model fit was improved. Main diagnoses of an organic mental or a psychotic disorder (ICD-10 groups F0 and F2), suicidal behavior upon admission, admission outside of regular service hours and absence of outpatient treatment prior to admission were confirmed as powerful predictors of detention. Particularly high risks were shown for (1) patients with an organic mental disorder, specifically if they were retired, admitted outside of regular service hours and lived in assisted housing, (2) patients with suicidal tendencies upon admission who did not suffer from an affective disorder, specifically if it was unclear whether there had been previous suicide attempts, or if the affected person lived in areas with high unemployment rates, and (3) patients with psychosis, specifically those who lived in densely built areas with a large proportion of small or one-person households.

CONCLUSIONS

Certain psychiatric diagnoses and suicidal tendencies are major risk factors for involuntary psychiatric hospitalization. In addition, service-related and environmental socioeconomic factors contribute to the risk for detention. Identifying modifiable risk factors and particularly vulnerable risk groups should help to develop suitable preventive measures.

Activities on acute mental health inpatient wards: A narrative synthesis of the service users' perspective

WHAT IS KNOWN ON THE SUBJECT?: Boredom is a big issue on inpatient mental health wards that is linked to poor patient satisfaction, feelings of frustration and increased incidents of self-harm and aggression. This is even more so for people detained under the Mental Health Act. Where wards have a good range of activities, for example art, music, computer games, gardening and exercise, service users felt less bored and had improved well-being. Over many years, studies have reported a lack of activities, especially during evenings and weekends. It has also been found that little is known about what activities service users want, or how activities might be meaningful for them. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This review found that very few studies have asked service users about what activities would be useful and why. By seeing what makes activities desirable and accessible, we can understand how to improve the experiences of service users on wards. Overall, these data help to understand what impact activities (or lack of activities) have on service users and staff experiences on these wards. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Through identifying the activities most appreciated and engaged with by service users and by asking service users what activities they would like available, we can inform best practice guidance for the commissioning and provision of inpatient mental health care. This will enable service provider organizations to target their effort and resources on supporting good practice and to redirect resources from less useful activities. ABSTRACT: Background Concern about the lack of activities on mental health inpatient wards is long-standing with reports consistently finding that service users receive insufficient access to a range of activities and report high levels of boredom. There is recognition that little is known about what service users want when admitted to inpatient wards. Aim This review seeks to understand service users' experiences and views in relation to the provision and availability of activities, and to explore the perceived benefits and barriers to service users. Methods We searched multiple databases (Scopus, MEDLINE, CINAHL, PsycINFO and Embase) for studies that evaluated activities on acute adult inpatient mental health wards. We identified 12 papers across a range of methodological designs from which the narrative synthesis has been analysed. Results Findings show that the provision of activities is unsatisfactory for many service users, which in turn is related to increased boredom that has a negative impact on service users' well-being. We explore the benefits and barriers to engagement, providing an insight into the aspects that make an activity important. Conclusion There are few studies exploring the needs of service users regarding activity provision; therefore, there is limited knowledge about what is meaningful for individuals.

PROTECT: Relational safety based suicide prevention training frameworks

Preventing suicide is a global priority, and staff training is a core prevention strategy. However, frontline pressures make translating training into better care and better outcomes difficult. The aim of the paper was to highlight challenges in suicide risk assessment and management and introduce training frameworks to assist with mindful practice so professionals can strike a balance between risk and recovery. We combined the scientific literature with contemporary practice from two successful initiatives from Cambridgeshire, UK: 333 - a recovery-oriented model of inpatient/community crisis care and PROMISE - a programme to reduce coercion in care by enhancing patient experience. The resulting PROTECT (PROactive deTECTion) frameworks operationalize ongoing practice of relational safety in these programmes. PROTECT is a combination of novel concepts and adaptations of well-established therapeutic approaches. It has four training frameworks: AWARE for reflection on clinical decisions; DESPAIR for assessment; ASPIRE for management; and NOTES for documentation. PROTECT aims to improve self-awareness of mental shortcuts and risk-taking thresholds and increase rigour through time-efficient cross-checks. The training frameworks should support a relational approach to self-harm/suicide risk detection, mitigation, and documentation, making care safer and person-centred. The goal is to enthuse practitioners with recovery-oriented practice that draws on the strengths of the person in distress and their natural circle of support. It will provide the confidence to engage in participatory approaches to seek out unique individualized solutions to the overwhelming psychological pain of suicidal distress. Future collaborative research with people with lived and carer experience is needed for fine-tuning.

The restraint chair: A qualitative study of nurses' experience with the restraint chair versus four point restraint

Restraint and seclusion continues to be a challenging topic in psychiatric nursing care. While there is a movement toward reduction and elimination of restraint, emergency situations still arise that require intervention for the safety of patients and staff. In addition to traditional methods of restraint (physical holds, four-point restraint, seclusion), the restraint chair has been introduced at some hospitals as an alternative to four-point restraint. The restraint chair allows the patient to be upright in a seated position during the restraint process. Little research on the restraint chair currently exists. The purpose of this study was to examine the nurses' experience with the restraint chair compared to four-point restraint. Results indicate nurses feel the restraint chair is easier to use, more humane, less traumatic, comforting, and enhances the therapeutic relationship compared to four-point restraint. Based on the reports of nurses in this study and prior quantitative work on the restraint chair (Castillo, Coyne, Chan, Hall, & Vilke, 2011; Visaggio et al., 2018), the restraint chair appears to be a safe and effective alternative to traditional four-point restraint. More research verifying these results at other hospitals in the United States and abroad is warranted.

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.

The effect of psychoeducation given to psychiatry nurses on level of knowledge, attitudes, and practices regarding physical restraint: A randomized controlled study

PURPOSE

This study aims to determine the effect of psychoeducation, given to nurses working in a psychiatry clinic, on level of knowledge, attitudes, and practices regarding physical restraint.

DESIGN AND METHODS

This study was conducted with a randomized-controlled-study design. A total of 111 nurses were recruited and randomly assigned to experimental (n = 53) and control (n = 58) groups. The experimental group received psychoeducation, while no intervention was applied to the control group. This study was conducted in a psychiatric hospital located in the Eastern Anatolia of Turkey. A Descriptive Form and the Levels of Knowledge, Attitudes, and Practices of Nurses Regarding Physical Restraints Questionnaire were used to collect data.

FINDINGS

Statistically significant differences were found between the pretest and posttest total mean scores on the level of knowledge (P = .000), attitudes (P = .000), and practices (P = .000) of the nurses in the control group and the study group.

PRACTICE IMPLICATIONS

An increase in the level of knowledge and positive improvement in attitudes and practices were observed in the nurses who received psychoeducation. Providing nurses with psychoeducation on physical restraint can positively contribute to improving their level of knowledge and to eliminating their negative attitudes and practices on this subject.

Physical restraint in mental health nursing: A concept analysis

OBJECTIVE

Physical restraint is frequently used in medical services, such as in mental health settings, intensive care units and nursing homes, but its nature varies in different institutions. By reviewing related literature, this study aims to clarify the concept of physical restraint in mental health nursing.

METHOD

Three databases (PubMed, PsycINFO and CINAHL) were retrieved, and Walker and Avant's concept analysis method was used to analyze the concept of physical restraint in mental health nursing.

RESULTS

Physical restraint is a coercive approach that enables the administration of necessary treatment by safely reducing the patient's physical movement. It should be the last option used by qualified personnel. Antecedents of physical restraint are improper behavior (violence and disturbance) of patients, medical assessment prior to implementation and legislation governing clinical usage. Consequences of physical restraint are alleviation of conflict, physical injury, mental trauma and invisible impact on the institution.

DISCUSSION

This study defined the characteristics of physical restraint in mental health nursing. The proposed concept analysis provided theoretical foundation for future studies.

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

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

PROGRESS: the PROMISE governance framework to decrease coercion in mental healthcare

Reducing physical intervention in mental health inpatient care is a global priority. It is extremely distressing both to patients and staff. PROactive Management of Integrated Services and Environments (PROMISE) was developed within Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) to bring about culture change to decrease coercion in care. This study evaluates the changes in physical intervention numbers and patient experience metrics and proposes an easy-to-adopt and adapt governance framework for complex interventions. PROMISE was based on three core values of: providing a caring response to all distress; courage to challenge the status quo; and coproduction of novel solutions. It sought to transform daily front-line interactions related to risk-based restrictive practice that often leads to physical interventions. PROactive Governance of Recovery Settings and Services, a five-step governance framework (Report, Reflect, Review, Rethink and Refresh), was developed in an iterative and organic fashion to oversee the improvement journey and effectively translate information into knowledge, learning and actions. Overall physical interventions reduced from 328 to 241and210 across consecutive years (2014, 2015-2016 and 2016-2017, respectively). Indeed, the 2016-2017 total would have been further reduced to 126 were it not for the perceived substantial care needs of one patient. Prone restraints reduced from 82 to 32 (2015-2016 and 2016-2017, respectively). During 2016-2017, each ward had a continuous 3-month period of no restraints and 4 months without prone restrains. Patient experience surveys (n=4591) for 2014-2017 rated overall satisfaction with care at 87%. CPFT reported fewer physical interventions and maintained high patient experience scores when using a five-pronged governance approach. It has a summative function to define where a team or an organisation is relative to goals and is formative in setting up the next steps relating to action, learning and future planning.

The Role of Religion, Spirituality and/or Belief in Positive Ageing for Older Adults

(1) Background: The concept of positive ageing is gaining recognition as an approach to better understand the lives of older adults throughout the world. Positive ageing encompasses the various ways in which older adults approach life challenges associated with ageing and how certain approaches allow older adults to age in a more positive way. This paper makes a contribution to the field by examining the role of religion, spirituality and/or belief in relation to positive ageing; (2) Methods: Qualitative focus groups with 14 older adults living in West London explored the role and importance religion, spirituality and/or belief held in their everyday lives and how this could be incorporated into the idea of positive ageing; (3) Results: Religion, spirituality and/or belief were found to play a number of roles in the everyday lives of the older adults, including being a source of strength, comfort and hope in difficult times and bringing about a sense of community and belonging; (4) Conclusion: This paper argues that religion, spirituality and/or belief should be included within positive ageing literature and be viewed as a type of support (amongst multiple others) that helps older adults to live positive lives despite the many challenges of ageing.