Prevalence of the use of chemical restraint in the management of challenging behaviours associated with adult mental health conditions: A meta-synthesis

Our Wished-for Responses: Recommendations for Creating a Lived and Embodied Sense of Safety During Mental Health Crisis

BACKGROUND

Medical interventions have a place in crisis support; however, narrow biomedical and risk-driven responses negatively impact people seeking crisis care. With increasing shifts towards involving people with lived experience (service users) in designing services, foregrounding people's desired responses is critical. Accordingly, the aim of the study was to explore the wished-for crisis responses from the perspective of people who have experienced crisis and accessed crisis care.

METHOD

Using a hermeneutical phenomenological approach, in-depth interviews were conducted to determine the desired crisis responses of 31 people who self-reported experiencing mental health crises and accessed crisis services at ED, phone lines and/or crisis alternatives.

RESULTS

The findings identified wished-for responses that gave a felt and embodied sense of their own safety influenced by a human-to-human response, emotional holding, a place of safety and choice within holistic care. For such responses to be possible, participants identified organising principles, including recognising crisis as meaningful and part of our shared human experience, understanding risk as fluid and a whole-of-community responsibility for responding to crises.

CONCLUSION

This paper proposes how insights from people who have experienced crises can be translated into more beneficial crisis care.

PATIENT OR CONSUMER CONTRIBUTION

Most authors are in identified lived experience roles. The first author engaged with participants during the recruitment and interviews and was explicit regarding their lived experience. Service users were involved as advisors, providing input throughout the study.

Evidence synthesis on coercion in mental health: An umbrella review

Coercion in mental healthcare is ubiquitous and affects the physical health, recovery and psychological and emotional well-being of those who experience it. Numerous studies have explored different issues related to coercion, and the present umbrella review aims to gather, evaluate and synthesise the evidence found across systematic reviews. The protocol, registered in the International Prospective Register of Systematic Reviews (PROSPERO registration number: CRD42020196713), included 46 systematic reviews and meta-analyses of primary studies whose main theme was coercion and which were obtained from databases (Medline/PubMed, PsycINFO, EMBASE and CINAHL) and repositories of systematic reviews following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. All the reviews were subjected to independent assessment of quality and risk of bias and were grouped in two categories: (1) evidence on specific coercive measures (including Community Treatment Orders, forced treatment, involuntary admissions, seclusion and restriction and informal coercion), taking into account their prevalence, related factors, effectiveness, harmful effects and alternatives to reduce their use; and (2) experiences, perceptions and attitudes concerning coercion of professionals, mental health service users and their caregivers or relatives. This umbrella review can be useful to professionals and users in addressing the wide variety of aspects encompassed by coercion and the implications for professionals' daily clinical practice in mental health units. This research received funding from two competitive calls.

The patient journey project in Italian mental health services: results from a co-designed survey on clinical interventions and current barriers to improve the care of people living with schizophrenia

Introduction

The Patient Journey Project aimed to analyze the scenario among Italian Mental Health Services (MHS) to understand the clinical interventions that are properly implemented and the ones deserving further implementation to design an effective treatment plan for patients living with schizophrenia (PLWS).

Methods

The 60-items survey was co-designed with all the stakeholders (clinicians, expert patients and caregivers) involved in the Patient Journey and focused on three phases of schizophrenia course: early detection and management, acute phase management, long-term management/continuity of care. Respondents were Heads of the Mental Health Departments and Addiction Services (MHDAS) or facilities directors throughout Italian MHS. For each statement, respondents expressed the consensus on the importance and the degree of implementation in clinical practice.

Results

Considering the importance of the statement, strong consensus was reached for most of the statements. Good levels of implementation were found on 2/17 statements of early detection and management, on 3/16 statements for acute phase management and on 1/27 statements of long-term management/continuity of care. Poor levels of implementation were found on 1/17 statements of early detection and management, none of acute phase management, and 4/27 statements for long-term management/continuity of care. Moderate levels of implementation were found on 14/17 statements for early detection and management, on 13/16 statements of acute phase management, and on 22/27 statements of long-term management/continuity of care. Thus, among Italian MHDAS, most interventions for PLWS were moderately implemented in clinical practice.

Discussion

Italian MHS have to provide new strategies and structural actions to overcome these current limitations and barriers to effectively improve the journey of PLWS. The areas that deserve most implementation include interventions during the early stage (especially the continuity of care between Child and Adolescent Mental Health Services and Adult Mental Health Services), the evidence-based psychosocial interventions during the chronic stages of the disorder, and the continuity of care after acute hospitalization.

Struggling with unnecessary suffering-Registered nurses' experiences of delayed decisions on treatment without consent in forensic psychiatric inpatient care

Chemical restraints are used in forensic psychiatric inpatient care, however with caution as it can feel like an assault against patients' integrity. When waiting for decisions on treatment without consent, nursing staff are expected to care for patients with severe mental ill-health without the use of medical treatment, often with a feeling of already having tried all other available means. Knowledge about how registered nurses experience such situations is sparse but could contribute to the development of both teamwork and nursing approaches that could mean reduced suffering for patients. The aim of this study was to describe registered nurses' experiences of delayed decisions on treatment without consent in forensic psychiatric inpatient care. Eleven semi-structured interviews were conducted with registered nurses working in forensic psychiatric units in Sweden. Data were analysed through qualitative content analysis. The result showed that experiences of treatment without consent were about striving to protect patients from harm, striving for collaboration during difficult circumstances and striving to do good. This was interpreted as a struggle with unnecessary suffering. For registered nurses to be able to handle such challenging situations and relieve suffering for patients, experience and master-level education in mental health nursing are highlighted. Another aspect that is highlighted is the importance of having consultants familiar with the circumstances at the unit. A method for joint reflection is suggested, to promote an open-minded work culture with a well-functioning decision-making process and ensure that both consultants and nursing staff have support.

The Use of Chemical Control Within Coercive Controlling Intimate Partner Violence and Abuse

This paper explores the use of chemical control by perpetrators as part of coercive controlling intimate partner violence and abuse, defined as the nonconsenting use of prescribed and nonprescribed medication (including vaccines), and/or other substances to coerce or control, reducing the victim-survivor's capacity for independence, freedom, and health. Based on testimonies of 37 victims-survivors and nine domestic abuse practitioners in the UK we identify varying tactics used to chemically coerce and control, deepening our understanding about the continually changing forms of domestic violence and abuse and enhancing the potential for a more robust response through better informed policy and practice.

Nurses' use of pro re nata medication in adult acute mental healthcare settings: An integrative review

This integrative review explores the current pro re nata (PRN) medication practice in acute adult mental health settings. PRN medication is commonly used in acute mental health settings but there is lack of evidence of effectiveness of this practice. PRN medications have a number of adverse effects and increase the risk of morbidity in patients with a mental illness. Articles were identified from MEDLINE, CINAHL, Scopus, PubMed, PsycINFO, and Web of Science database. The STROBE critical appraisal tool was used to evaluate the quality of evidence, and inductive thematic analysis was used to extract main themes. Five themes regarding prescription practices, poor documentation, reasons to administer, medication misuse, and insufficient use of non-pharmacological interventions emerged among the 12 eligible articles. The study identified PRN medication practice gaps in adult mental health settings included insufficient documentation practice, underuse of therapeutic non-pharmacological interventions, and significant variability in PRN medication practice across the mental health professionals due to different levels of knowledge and experience.

Nurses' clinical decision-making in the use of rapid tranquillization in adult mental health inpatient settings: An integrative review

Rapid tranquillization is a restrictive practice that remains widely used in mental health inpatient settings worldwide. Nurses are the professionals most likely to administer rapid tranquillization in mental health settings. To improve mental health practices, an enhanced understanding of their clinical decision-making when using rapid tranquillization is, therefore, important. The aim was to synthesize and analyse the research literature on nurses' clinical decision-making in the use of rapid tranquillization in adult mental health inpatient settings. An integrative review was conducted using the methodological framework described by Whittemore and Knafl. A systematic search was conducted independently by two authors in APA PsycINFO, CINAHL Complete, Embase, PubMed and Scopus. Additional searches for grey literature were conducted in Google, OpenGrey and selected websites, and in the reference lists of included studies. Papers were critically appraised using the Mixed Methods Appraisal Tool, and the analysis was guided by manifest content analysis. Eleven studies were included in this review, of which nine were qualitative and two were quantitative. Based on the analysis, four categories were generated: (I) becoming aware of situational changes and considering alternatives, (II) negotiating voluntary medication, (III) administering rapid tranquillization and (IV) being on the other side. Evidence suggests that nurses' clinical decision-making in the use of rapid tranquillization involved a complex timeline with various impact points and embedded factors that continuously influenced and/or were associated with nurses' clinical decision-making. However, the topic has received scant scholarly attention, and further research may help to characterize the complexities involved and improve mental health practice.

Rare Case of Managing and Evaluating Viability after Replantation of a Serial Self-Amputated Bilateral Testis by a Patient with Schizophrenia: A Case Report

Amputation of the testis is very rare in clinical situations; therefore, most surgeons have no experience with an amputated testis. In this case, a 31-year-old male with schizophrenia amputated both testes due to self-mutilation. We performed replantation surgery via microscopy. On postoperative day 1, he removed his right testis by using his hand, even though his hands were restrained. The second attack disrupted the viability of the right testis. However, after proper management, we checked the normal sex hormone level by preserving the replanted left testis. We evaluated the viability of the replanted testis by performing five examinations, namely, intraoperative indocyanine green injection, testicular scan with technetium pertechnetate, contrast-enhanced computerized tomography, Doppler ultrasonography, and serum testosterone level. In this report, we aimed to describe our rare experience about management with replantation of the amputated testes and evaluation of their viability.

The Patient Journey of Schizophrenia in Mental Health Services: Results from a Co-Designed Survey by Clinicians, Expert Patients and Caregivers

BACKGROUND

The Patient Journey Project aims to collect real-world experiences on schizophrenia management in clinical practice throughout all the phases of the disorder, highlighting virtuous paths, challenges and unmet needs.

METHODS

A 60-item survey was co-designed with all the stakeholders (clinicians, expert patients and caregivers) involved in the patient's journey, focusing on three areas: early detection and management, acute phase management and long-term management/continuity of care. For each statement, the respondents expressed their consensus on the importance and the degree of implementation in clinical practice. The respondents included heads of the Mental Health Services (MHSs) in the Lombardy region, Italy.

RESULTS

For early diagnosis and management, a strong consensus was found; however, the implementation degree was moderate-to-good. For acute phase management, a strong consensus and a good level of implementation were found. For long-term management/continuity of care, a strong consensus was found, but the implementation level was slightly above the cut-off, with 44.4% of the statements being rated as only moderately implemented. Overall, the survey showed a strong consensus and a good level of implementation.

CONCLUSIONS

The survey offered an updated evaluation of the priority intervention areas for MHSs and highlighted the current limitations. Particularly, early phases and chronicity management should be further implemented to improve the patient journey of schizophrenia patients.

'Stakeholders are almost always resistant': Australian behaviour support practitioners' perceptions of the barriers and enablers to reducing restrictive practices

A restrictive practice (RP) is defined as a practice or intervention that has the effect of restricting the rights or freedom of movement of a person, and includes physical, mechanical, and chemical restraint, and seclusion. If misused or overused, RPs may present serious human rights infringements. In Australia, behaviour support practitioners who deliver behaviour support funded by the National Disability Insurance Scheme are responsible for developing positive behaviour support plans that aim to reduce and eliminate the use of RPs. At present, little is known about the barriers that behaviour support practitioners experience when attempting to reduce and eliminate the use of RPs and, conversely, what helps (or enables) them to reduce and eliminate RPs. To learn more, we conducted an online survey consisting of two open-ended questions with 109 Australian behaviour support practitioners to identify barriers and enablers. We found that fear and reluctance on the part of stakeholders were often barriers to reducing the use of RPs. However, we found that having time, funding, and resources for training, supervision, other implementation activities, care team collaboration, and data-based decision-making helped overcome barriers. We provide specific recommendations for addressing identified barriers for individual behaviour support practitioners, service provider organisations, and government and regulatory agencies.

Association of Black Race With Physical and Chemical Restraint Use Among Patients Undergoing Emergency Psychiatric Evaluation

OBJECTIVE

Few studies have examined the disproportionate use of restraints for Black adults receiving emergency psychiatric care. This study sought to determine whether the odds of physical and chemical restraint use were higher for Black patients undergoing emergency psychiatric care compared with their White counterparts.

METHODS

This single-center retrospective cohort study examined 12,977 unique encounters of adults receiving an emergency psychiatric evaluation between January 1, 2014, and September 18, 2020, at a large academic medical center in Durham, North Carolina. Self-reported race categories were extracted from the electronic medical record. Primary outcomes were the presence of a behavioral physical restraint order or chemical restraint administration during the emergency department encounter. Covariates included age, sex, ethnicity, height, time of arrival, positive urine drug screen results, peak blood alcohol concentration, and diagnosis of a bipolar or psychotic disorder.

RESULTS

A total of 961 (7.4%) encounters involved physical restraint, and 2,047 (15.8%) involved chemical restraint. Models with and without a race covariate were compared by using quasi-likelihood information criterion scores; in each instance, the model with race performed better than the model without. Black patients were more likely to be physically (adjusted odds ratio [AOR]=1.35; 95% confidence interval [CI]=1.07-1.72) and chemically (AOR=1.33; 95% CI=1.15-1.55) restrained than White patients.

CONCLUSIONS

After analyses were adjusted for measured confounders, Black patients undergoing psychiatric evaluation were at higher odds of experiencing physical or chemical restraint compared with White patients, which is consistent with the growing body of evidence revealing racial disparities in psychiatric care.

A two-center pilot study on the effects of clinical ethics support on coercive measures in psychiatry

BACKGROUND

The use of formal coercion such as seclusion, mechanical restraint, and forced medication is one of the most challenging and complex issues in mental health care, on the clinical, the legal, and the ethical level. Clinical ethics support aims at assisting healthcare practitioners in determining the morally most justifiable course of action in these situations. However, the effectiveness of clinical ethics support has hardly been studied so far.

METHODS

Monthly moral case deliberation (MCD) was implemented in two acute wards of two different psychiatric hospitals in Switzerland. Frequency and intensity of coercion was measured on ward level (n_patients = 405), and the Moral Attentiveness Scale, Knowledge on Coercion Scale, and Staff Attitudes towards Coercion Scale were applied on healthcare practitioner level (n_HP = 46). Pre-post-comparisons were conducted using multi-level modeling where appropriate.

RESULTS

After implementation of MCD, formal coercion was less frequent (particularly seclusion, small effect size; 9.6 vs. 16.7%, p = .034, Cramér's V = .105) and less intense (particularly mechanical restraint, large effect size; 86.8 ± 45.3 vs. 14.5 ± 12.1 h, exact p = .019, r = -.74), and approval for coercive measures among healthcare practitioners was lower when controlling for the number of MCD sessions attended.

CONCLUSIONS

Clinical ethics support such as MCD may be a hitherto underutilized service for the reduction of coercion, complementing existing strategies and programs. Implementing clinical ethics support may help improve quality of care for persons suffering from severe mental illness.

Restraint practice in the somatic acute care hospital: A participant observation study

AIMS AND OBJECTIVES

We aimed to describe daily restraint practices and the factors which influence their use, from an outsider's perspective.

BACKGROUND

A reduction in restraint use is recommended in health care. However, somatic acute care hospital settings currently lack effective reduction strategies. Thus far, hospital restraint practice is described in terms of quantitative assessments and the 'insider' view of healthcare professionals. However, as factors such as routine or personal beliefs seem to play a relevant role in restraint use, these approaches might be incomplete and biased.

DESIGN

A qualitative observation study design was employed.

METHODS

Fieldwork with unstructured participant observation was conducted at a department of geriatrics and a department of intensive care in Switzerland between November 2019 and January 2020. Data were recorded as field notes. The analysis was conducted iteratively in two coding cycles using descriptive coding followed by pattern coding. We adhered to the Standards for Reporting Qualitative Research (SRQR).

RESULTS

A total of 67 hours of observation were conducted. We found that daily restraint practice can be described in three categories: the context in which restraints are used, the decision-making process on the use and continued use of restraints, and the avoidance of restraint use. Most processes and decisions seem to take place unconsciously, and their standardisation is weak.

CONCLUSIONS

The lack of standardisation favours intuitive and unreflective action, which is prompted by what is also known as heuristic decision-making. To transform daily restraint practice, a technical solution that leads restraint management in line with ethical and legal requirements might be useful.

RELEVANCE TO CLINICAL PRACTICE

The outsider perspective has allowed daily restraint practice to be described independently of existing routines, departmental cultures and personal attitudes. This is important to comprehensively describe restrictive practices, which is a prerequisite for the development of effective restraint reduction strategies.

Variation in restraint use between hospitals: a multilevel analysis of multicentre prevalence measurements in Switzerland and Austria

BACKGROUND

In restraint use in the somatic acute-care hospital setting, routine and institutional culture seem to play an important role. This implies that similar patient situations would be managed with restraints in one hospital, while in another hospital the situation would be managed without restraints. This practice variation appears to be ethically and legally questionable. The influence of organisation-specific factors such as the availability of guidelines is discussed. However, the relevance of such factors at the hospital level has been rarely investigated to date. Therefore, the aims of this study were a) to determine how much variance in restraint use can be explained on the hospital level (hospital general effect) and b) to examine the impact of organisational factors on restraint use (specific contextual effects).

METHODS

A secondary data analysis of cross-sectional multicentre data was performed. Data were collected during three quality measurements (2016-2018) in acute-care hospitals in Switzerland and Austria. Hospitalised patients from different medical specialties aged 18+ with informed consent were included. Descriptive analysis and multilevel logistic regression analysis were performed.

RESULTS

The study included 29,477 patients from a total of 140 hospitals. The 30-day prevalence rate of patients with at least one restraint was 8.7% (n = 2577). The availability of guidelines regarding restraint use and refresher courses for nursing staff were associated with less restraint use (odds ratios = 0.60 and 0.75). By adding the hospital as a random effect, the explained variance of the model increased from 24 to 55%.

CONCLUSIONS

The use of restraints varies widely between hospitals, even considering patient characteristics. The identification of situations in which restraints were used out of routine or institutional culture appears to be an important approach in restraint reduction. Investments in appropriate structures and employee knowledge can facilitate providing restraint-free care as much as possible.

Chemical restraint: A qualitative synthesis review of adult service user and staff experiences in mental health settings

With an imperative to reduce or eliminate the use of coercive practices in mental health care it is important to understand the experience of service users and staff. This review aimed to synthesize qualitative studies, published between 1996 and 2020, reporting on mental health service users' and staff's experiences of chemical restraint. The databases PsycINFO, CINAHL, MEDLINE, Embase, Emcare, Web of Science, and Scopus were searched. Three analytic themes were identified from 17 included articles, synthesizing the experiences of service users and staff. These were "Unjustified versusjustified," "Violence versus necessity," and "Reflecting back: Positives and negatives." Service users viewed chemical restraint as an unjustified response to "behaviors of concern" and experienced it as a violent act with negative outcomes, although some saw it as necessary in retrospect and preferred it to other forms of coercion. Staff generally viewed it as a justified response to "behaviors of concern" and experienced it as appropriate within the constraints of staff numbers and limited alternatives. These findings identify nuances not apparent in the literature, which has generally conflated all forms of coercive practices.