Frequency of physical restraint and its associations with demographic and clinical characteristics in a Chinese psychiatric institution

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.

Perspectives on physical restraint in psychiatric hospital: A qualitative study of mentally ill patients

The use of physical restraint had caused a series of unexpected impacts on patients, particularly psychological trauma. This qualitative study aimed to identify perspectives on physical restraint among patients with mental health conditions and to seek effective interventions targeting the psychological trauma which is caused by physical restraint. A semi-structured interview was conducted in a public psychiatric hospital in China to explore perspectives on physical restraint among 26 patients who had undergone or witnessed physical restraint. The interview was conducted by experienced and qualified interviewers with mental health service backgrounds. The interviews were recorded and transcribed into words, and then preliminary themes were extracted and coded, finally thematic analysis was used to identify focused themes. Five themes were extracted: these were as follows: (1) The negative effects of physical restraint on patients; (2) The impairment of the relationship between nurse and patient due to physical restraint; (3) The decrease in patients' treatment adherence caused by physical restraint; (4) The positive outcomes of physical restraint; (5) The expectations of patients for improving the quality of nursing care. Conclusively, the use of physical restraint had critical impacts on patients, including psychological trauma, destruction of the nurse-patient relationship, and decreased adherence of treatment. These negative effects could impede clinical work.

Offenders and non-offenders with schizophrenia spectrum disorders: the crime-preventive potential of sufficient embedment in the mental healthcare and support system

Background

Suffering from schizophrenia spectrum disorder (SSD) has been well-established as a risk factor for offending. However, the majority of patients with an SSD do not show aggressive or criminal behavior. Yet, there is little research on clinical key features distinguishing offender from non-offender patients. Previous results point to poorer impulse control, higher levels of excitement, tension, and hostility, and worse overall cognitive functioning in offender populations. This study aimed to detect the most indicative distinguishing clinical features between forensic and general psychiatric patients with SSD based on the course of illness and the referenced hospitalization in order to facilitate a better understanding of the relationship between violent and non-violent offenses and SSD.

Methods

Our study population consisted of forensic psychiatric patients (FPPs) with a diagnosis of F2x (ICD-10) or 295.x (ICD-9) and a control group of general psychiatric patients (GPPs) with the same diagnosis, totaling 740 patients. Patients were evaluated regarding their medical (and, if applicable, criminal) history and the referenced psychiatric hospitalization. Supervised machine learning (ML) was used to exploratively evaluate predictor variables and their interplay and rank them in accordance with their discriminative power.

Results

Out of 194 possible predictor variables, the following 6 turned out to have the highest influence on the model: olanzapine equivalent at discharge from the referenced hospitalization, a history of antipsychotic prescription, a history of antidepressant, benzodiazepine or mood stabilizer prescription, medication compliance, outpatient treatment(s) in the past, and the necessity of compulsory measures. Out of the seven algorithms applied, gradient boosting emerged as the most suitable, with an AUC of 0.86 and a balanced accuracy of 77.5%.

Discussion

Our study aimed to identify the most influential illness-related predictors, distinguishing between FPP and GPP with SSD, thus shedding light on key differences between the two groups. To our knowledge, this is the first study to compare a homogenous sample of FPP and GPP with SSD regarding their symptom severity and course of illness using highly sophisticated statistical approaches with the possibility of evaluating the interplay of all factors at play.

Psychiatric Nurses' Knowledge, Attitudes, and Practice Regarding Physical Restraint in China: A Multicentre Cross-Sectional Study

Background

Physical restraint is widely used in mental health services to address safety concerns. However, studies have shown that improper physical restraint can result in adverse effects. Nurses are the main practitioners of physical restraint and play a crucial role in physical restraint decisions and nursing. In China, there is a lack of large-scale investigations into the current status of psychiatric physical restraint use.

Aim

This study aims to explore the situation and influencing factors of the psychiatric nurses' knowledge, attitudes and practices regarding physical restraint in China.

Methods

A cross-sectional multicenter descriptive study was conducted from December 2022 to February 2023, consecutively. A convenience sampling method was used to recruit 345 staff from three psychiatric hospitals in Shanghai. A psychiatric nurses' physical restraint use status questionnaire was administered to examine their knowledge, attitude, and practice regarding physical restraint. The data were analyzed using the Mann-Whitney U-test and the Kruskal-Wallis test. Multivariate linear stepwise regression analysis was used for multi-factor analysis.

Results

Overall, nurses had a good level of knowledge with positive attitudes and adequate practices. However, they had some misunderstandings and undesirable practices. Multiple linear regression analysis revealed that educational background, position and training experience were the main factors influencing physical restraint knowledge, attitudes and practice among psychiatric nurses (p<0.05).

Conclusion

This study highlights some important misconceptions and improper practices of psychiatric nurses about using physical restraint. It is necessary to strengthen education and training on physical restraint for nursing staff to reduce unnecessary physical restraint use.

The optimal intervention for preventing physical restraints among older adults living in the nursing home: A systematic review

AIM

This study aimed to evaluate the effectiveness of restraint reduction programs for nursing home care providers in enforcing physical restraint on residents and identify the best strategies for such programs.

DESIGN

Systematic Review.

METHODS

We searched for randomized controlled trials published until February 2021 for systematic review. The systematic review captured multifactorial interventions, education and consultation measures, including nursing home residents' and care providers' results. Study quality was assessed using the Cochrane Collaboration criteria.

RESULTS

In all seven trials, the interventions were led by a nurse specialist or unit leader and targeted at care providers. Five of the restraint reduction programs effectively reduced the rate of physical restraint use; two increased knowledge of restraint reduction for care providers; and one each promoted positive attitudes and behaviours. Duration of at least 6 weeks significantly improved the knowledge of care providers.

Organizational citizenship behaviour as a protective factor against the occurrence of adverse nursing-sensitive outcomes: A multilevel investigation

AIMS

This study aimed to investigate the association between organizational citizenship behaviour enacted by nurses and the occurrence of adverse nursing-sensitive patient outcomes.

BACKGROUND

Managing psychosocial factors (i.e., aspects concerning the work environment) is key to ensure patient safety, to prevent exacerbation of case complexity and to cope with critical shortages in human and financial resources.

METHODS

Self-report measures of nurses' organizational citizenship behaviour were combined with objective data on the incidence of adverse nursing-sensitive outcomes (i.e., pressure ulcers and restraint use) collected through patients' medical records. Participants were 11,345 patients and 1346 nurses across 52 teams working in 14 Italian hospitals. Data were analysed using multilevel binary logistic regression models.

RESULTS

A negative relationship between nurses' organizational citizenship behaviour and restraint use was identified, with an odds ratio of 0.11. Thus, for a one-unit higher organizational citizenship behaviour score, the odds of using restraints shrink to about one eighth of the previous level.

CONCLUSIONS

Intervention strategies to foster the implementation of organizational citizenship behaviour among nurses may inhibit the occurrence of critical outcomes affecting patients' health and well-being (i.e., using restraint devices).

IMPLICATIONS FOR NURSING MANAGEMENT

In health care organizations, shaping a psychosocial environment encouraging organizational citizenship behaviour can mitigate the occurrence of adverse nursing-sensitive outcomes such as restraint use on patients.

Nurses' attitudes towards the use of physical restraint in psychiatric care: A systematic review of qualitative and quantitative studies

WHAT IS KNOWN ON THE SUBJECT?: Application of physical restraint is a common practice to protect service users and staff in psychiatric care. Nurses' attitudes towards physical restraint and its influencing factors in psychiatric settings in different countries are variable. Previous reviews include studies on different coercive methods, making it difficult to differentiate attitudes specific to physical restraint. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Nurses' attitudes were marked by negative feelings and moral conflict towards the use of physical restraint and consider it a necessary nursing intervention and a last resort. The barriers for restraint-free environment practice included contextual demand, lack of knowledge on restraint and lack of alternatives to restraint. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurse educators should develop and evaluate related educational training programmes to promote the development of alternative effective skills in handling violence instead of physical restraint. Policy makers should develop strategies to remove the barriers to a restraint-free environments. ABSTRACT: Introduction Physical restraint is common in psychiatric care; nurses' attitudes are crucial as nurses often implement the procedure. Previous reviews include studies exploring coercive methods but do not specifically focus on physical restraint. Aims This integrated mixed-method systematic review aimed to examine nurses' attitudes towards the use of physical restraint in psychiatric care and the factors influencing these attitudes. Methods Six databases were searched from 2000 to 2021. Thematic integrative analysis was used to synthesize the data. Results Ten studies were included. Five themes encapsulate nurses' attitudes towards physical restraint: "emotional responses," "moral conflicts," "ensuring safety for all," "a necessary nursing intervention" and "a last resort." Three themes were identified for factors influencing attitudes: "contextual demands," "level of knowledge" and "alternatives to restraint." Discussion Nurses' attitudes were marked by negative feelings and moral conflict towards the use of physical restraint. However, nurses applied physical restraint as an ordinary nursing intervention. Educational interventions and the leadership role may facilitate the change of current practice to a restraint-free environment. Implications for Practice Mental health nurses should work to remove the barriers to restraint-free environment and develop effective skills that can be used as alternatives to physical restraint.

Physical Restraint Events in Psychiatric Hospitals in Hong Kong: A Cohort Register Study

The need to better monitor coercion practices in psychiatric hospitals has been recognised. We aim to describe how physical restraint events occur in psychiatric hospitals and identify factors associated with physical-restraint use. A cohort register study was used. We analyzed physical restraint documents among 14 wards in two psychiatric hospitals in Hong Kong (1 July and 31 December 2018). In total, 1798 incidents occurred (the rate of physical restraint event 0.43). Typically, physically restrained patients were in early middle-age, of both genders, diagnosed with schizophrenia-spectrum and other psychotic disorders, and admitted voluntarily. Alternate methods for physical restraint were reported, such as an explanation of the situation to the patients, time-out or sedation. A longer period of being physically restrained was associated with being male, aged ≥40 years, having involuntary status, and neurodevelopmental-disorder diagnosis. Our findings support a call for greater action to promote the best practices in managing patient aggression and decreasing the use of physical restraint in psychiatric wards. The reasons for the use of physical restraint, especially for those patients who are admitted to a psychiatric hospital on a voluntary basis and are diagnosed with neurodevelopmental disorders, needs to be better understood and analysed.

An Evaluation of the Implementation of a "No Force First" Informed Organisational Guide to Reduce Physical Restraint in Mental Health and Learning Disability Inpatient Settings in the UK

BACKGROUND

The use of physical restraint on vulnerable people with learning disabilities and mental health problems is one of the most controversial and criticised forms of restrictive practice. This paper reports on the implementation of an organisational approach called "No Force First" within a large mental health organisation in England, UK. The aim was to investigate changes in violence/aggression, harm, and physical restraint following implementation.

METHODS

The study used a pretest-posttest quasi-experimental design. Recorded incidents of violence/aggression from 44 inpatient mental health and learning disabilities (including forensic) wards were included (n = 13,599). Two study groups were created for comparison: the "intervention" group comprising all incidents on these wards during the 24 months post-implementation (2018-2019) (n = 6,551) and the "control" group comprising all incidents in the 24 months preceding implementation (2015-2016) (n = 7,048). Incidents recorded during implementation (i.e., 2017) were excluded (n = 3,705). Incidence rate ratios (IRR) were calculated with 95% confidence intervals (95% CI). Multivariate regression models using generalised estimating equations were performed to estimate unadjusted and adjusted prevalence ratios (aPR) of physical restraint and harm, using type of wards, incident, and violence/aggression as key covariates.

RESULTS

A significant 17% reduction in incidence of physical restraint was observed [IRR = 0.83, 95% CI 0.77-0.88, p < 0.0001]. Significant reductions in rates of harm sustained and aggression/violence were also observed, but not concerning the use of medication during restraint. The prevalence of physical restraint was significantly higher in inpatients on forensic learning disability wards than those on forensic mental health wards both pre- (aPR = 4.26, 95% CI 2.91-6.23) and post-intervention (aPR = 9.09, 95% CI 5.09-16.23), when controlling for type of incident and type of violence/aggression. Physical assault was a significantly more prevalent risk factor of restraint use than other forms of violence/aggression, especially that directed to staff (not to other patients).

CONCLUSIONS

This is a key study reporting the positive impact that organisational models and guides such as "No Force First" can have on equipping staff to focus more on primary and secondary prevention as opposed to tertiary coercive practices such as restraint in mental health and learning disabilities settings.

Determinants of mechanical restraint in an acute psychiatric care unit

BACKGROUND

Despite numerous attempts to reduce the use of mechanical restraint (MR), this technique continues to be widely applied in many acute psychiatric care settings. In order to reduce MR, a better understanding of the variables associated with its use and duration in different clinical environments is essential.

AIM

To determine the proportion of patients subjected to MR and the duration thereof in two acute care psychiatric units; and to identify the variables associated with the use and duration of MR.

METHODS

Descriptive study of all patients admitted to the acute psychiatric units at the Parc de Salut Mar (Barcelona, Spain) in the year 2018. The number and percentage of patients subjected to MR, as well as the duration of each episode were assessed. The following data were also registered: sociodemographic characteristics, psychiatric diagnosis, and presence of cultural and/or language barriers. Multivariate analyses were performed to assess determinants of MR and its duration.

RESULTS

Of the 464 patients, 119 (25.6%) required MR, with a median of 16.4 h per MR. Two factors - a diagnosis of psychotic disorder [Odds ratios (OR) = 0.22; 95%CI: 0.06-0.62; P = 0.005] and the presence of a language barrier (OR = 2.13; 95%CI: 1.2-3.7; P = 0.007) - were associated with a significantly higher risk of MR. Male sex was associated with a longer duration of MR (B = -19.03; 95%CI: -38.06-0.008; P = 0.05).

CONCLUSION

The presence of a language barrier and a psychotic disorder diagnosis are associated with a significantly higher risk of MR. Furthermore, male sex is associated with a longer duration of MR. Individualized restraint protocols that include the required tools are necessary to ultimately limit the use of mechanical restraint.

The Knowledge, Practice and Attitudes of Nurses Regarding Physical Restraint: Survey Results from Psychiatric Inpatient Settings

There is a considerable amount of literature describing how nurses’ knowledge contributes to their attitudes and practices related to patient physical restraint. However, whether or not there have been any improvements in nurses’ knowledge levels, attitudes or practices regarding physical restraint during the past few years is unknown. A survey was conducted on nurses (n = 133) in one psychiatric hospital in Hong Kong (n = 98, response rate = 74%). The data were analyzed using independent t-tests, ANOVA, a Mann–Whitney U test, a Kruskal–Wallis test and Spearman’s rho. In general, nurses had good restraint-related knowledge with satisfactory attitudes and practices, although their knowledge levels, attitudes, and practices regarding restraint varied. Having a higher age, seniority, and education level contributed to a higher restraint-related knowledge level. Male nurses demonstrated more desirable practices (i.e., care of restrained patients), while nurses with a higher education level were more likely to avoid restraint. Nurses’ restraint-related knowledge positively correlated with restraint practices. Although nurses’ knowledge levels, attitudes, and practices regarding restraint were found to be satisfactory, more training efforts should focus on young nurses working in psychiatric settings with less work experience and lower education levels. As some nurses seem to favor the use of restraint with limited reflection, more studies are needed to verify nurses’ emotions and how their emotions influence the use of restrictive practices.

Attitude and practice toward physical restraint among psychiatric nurses in Guangdong, China: a cross-sectional survey†

Objective

To explore the correlation between nurses’ attitude and practice toward physical restraint (PR) in psychiatric settings and identify the factors that influence the use of PR.

Methods

A cross-sectional survey was conducted. A self-designed questionnaire containing a PR scale was used to assess the attitude and practice of registered psychiatric nurses in Guangdong, China, from November 1, 2018 to December 31, 2018. Descriptive statistics, the Mann–Whitney U test, the Kruskal–Wallis test, and ordinal regression analysis were used to analyze the data.

Results

The response rate was 74.6%. The nurses’ responses showed neutral attitude and a moderate level of practice regarding the use of PR. Factors such as age, gender, marital status, professional position, nightshift, and the frequency of training programs on PR showed a significant association with nurses’ attitude and practice concerning PR (P < 0.05). In addition to these factors, this study found that the practice of PR was associated with nurses’ attitude toward it (P < 0.05). Our results showed that nurses with a largely negative attitude toward PR were more likely to use it (OR = 1.91, P < 0.001).

Conclusions

Clinically, psychiatric nurses with negative attitude are more likely to practice PR. Training and education programs are highly recommended for nursing managers to change the nursing staff’s attitude, since their attitude may have an impact on the PR what they practice.

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).

The use of physical restraints in Chinese long-term care facilities and its risk factors: An observational and cross-sectional study

AIM

To investigate the use of physical restraints among Chinese long-term care facilities older adults and to identify its risk factors.

DESIGN

Observational and cross-sectional study.

METHODS

A total of 1,026 older adults from six long-term care facilities in Chongqing were recruited by cluster sampling method from July - November 2019. Data on physical restraint use and older adults' characteristics were collected using physical restraints observation forms and older adults' records. Organizational data were collected by questionnaires asking nursing managers. The independent risk factors for physical restraints use were assessed using chi-square test and binary logistic regression.

RESULTS

The study found that the prevalence of physical restraints in six long-term care facilities in China was 25.83%. Waist belt (55.47%) and wrist restraint (52.83%) were most frequently used. Only 61.51% of physical restraints were signed with informed consent. 71.70% of physical restraints were caused by the prevention of falls, 89.06% of physical restraints were without nursing documentation, and 13.58% restrained older adults were observed to have physical complications. According to the binary logistic regression analysis, facility type and ownership, older adults per nursing assistant, length of residence, cognitive impairment, care dependency, mobility restriction, fall risk, physical agitation, and indwelling tubes emerged as important risk factors for the use of physical restraints.

CONCLUSION

The use of physical restraints among Chinese long-term care facilities older adults was at a relatively high level and lack standardized and regulated practices. Moreover, Physical restraint use was associated with facility type and ownership, older adults per nursing assistant, length of residence, cognitive impairment, care dependency, mobility restriction, fall risks, physical agitation, and indwelling tube.

IMPACT

This study will provide an effective reference for nursing staff in long-term care facilities to assess high-risk older adults in their use of physical restraints, which can support them to implement effective minimized restraint approaches to targeted people.

Aims to Reduce Coercive Measures in Forensic Inpatient Treatment: A 9-Year Observational Study

Protecting the human rights is particularly important within the forensic context because patients in forensic psychiatry are not admitted voluntarily and so the treatment itself is of a coercive nature. Coercive measures (i.e., actions against the will of the patient such as forced medication, seclusion or restraint) form an additional incision of personal rights. Although the use of coercion within forensic psychiatric institutions remains controversial, little empirical research has been conducted on the use of coercive measures within forensic settings. The study presented here can contribute to close this research gap by informing about rates of coercive measures within the present institution. National and international organizations on the prevention of torture or inhuman or degrading treatment have emphasized the need to keep the incidents of coercive measures to a minimum. Criticisms by such organizations on high rates of seclusion, restraint, and compulsory medication have led to organizational changes within the present institution which is Switzerland's largest forensic clinic with an average of 124 patients per year. After a first visit of such a committee, e.g., the detailed documentation of coercive measures became obligatory and part of special reports. Changes in the use of coercive measures are presented here. Data on coercive measures was analyzed for years 2010 to 2018. With respect to the most invasive coercive measurement, restraint, a minimum of four patients in 2017 and a maximum of 14 patients in 2010 have been subject to this form of coercive measurement. A minimum of sixteen patients in 2012 and a maximum of 40 patients in 2010 were secluded. Though total number and duration show a trend towards a reduction in severity of coercive measures on average, a few patients are not responsive to deescalating interventions. Preventive mechanisms, documentation standards, and efforts to ensure humane and adequate treatment are discussed under ethical considerations of coercive measures within court mandated treatment.

Identifying Direct Coercion in a High Risk Subgroup of Offender Patients With Schizophrenia via Machine Learning Algorithms

PURPOSE

This study aims to explore risk factors for direct coercive measures (seclusion, restraint, involuntary medication) in a high risk subpopulation of offender patients with schizophrenia spectrum disorders.

METHODS

Five hundred sixty nine potential predictor variables were explored in terms of their predictive power for coercion/no coercion in a set of 131 (36.6%) offender patients who experienced coercion and 227 who did not, using machine learning analysis. The dataset was split (70/30%) applying variable filtering, machine learning model building, and selection embedded in nested resampling approach in one subset. The best model was then selected, and the most important variables extracted on the second data subset.

RESULTS

In the final model the following variables identified coercion with a balanced accuracy of 73.28% and a predictive power (area under the curve, AUC) of 0.8468: threat of violence, (actual) violence toward others, the application of direct coercive measures during past psychiatric inpatient treatments, the positive and negative syndrome scales (PANSS) poor impulse control, uncooperativeness, and hostility and the total PANSS-score at admission, prescription of haloperidol during inpatient treatment, the daily cumulative olanzapine equivalent antipsychotic dosage at discharge, and the legal prognosis estimated by a team of licensed forensic psychiatrists.

CONCLUSIONS

Results confirm prior findings, add detail on factors indicative for the use of direct coercion, and provide clarification on inconsistencies. Limitations, clinical relevance, and avenues for future research are discussed.

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.

Staff Training Reduces the Use of Physical Restraint in Mental Health Service, Evidence-based Reflection for China

OBJECT

The purpose of this article was to synthesize the evidence regarding the reduction of physical restraint, and to seek some practical recommendations based on the current situation in China.

METHOD

Nine databases were retrieved; these were PubMed, CINAHL, MEDLINE, Trip Database, PsysINFO, Cochrane Library, CNKI (Chinese database), Wanfang (Chinese database) and CBM (Chinese database) respectively. The selected articles were screened manually, and the identified researches were appraised through Review manager 5.3.

RESULT

Eight studies (four randomized controlled trials and four quasi-experimental studies) published between June 2013 and May 2017 were selected. Risk ratios (RRs) with 95% confidence intervals (CIs) were used as the effect index for dichotomous variables. The standardized mean differences (SMDs) with 95% CIs were calculated as the pooled continuous effect. The outcome of meta-analysis suggested staff training reduced the duration (IV=-0.88; 95% CIs=-1.65 to -0.10; Z=2.22; p=0.03) and adverse effect (RR, 0.16; 95% CIs=0.09 to 0.30; Z=5.96; p<0.00001) of physical restraint, but there were no statistical change in the frequency of physical restraint (RR, 0.74; 95% CIs=0.43 to 1.28; Z=1.07; p=0.28). Noticeably, the result of pooled estimates from 3 RCTs suggested staff training had no effects on the incidence of physical restraint. (RR, 1.01; 95% CIs=0.45 to 2.24; Z=0.02; p=0.99) CONCLUSION: Staff training was an effective measure to minimize the duration and adverse effects of physical restraint. More studies are needed to examine the effectiveness of staff training in relation to reduce the prevalence of physical restraint. Furthermore, considering the nurse's education background in China, it is recommended to conduct a compulsory training program to reduce the unnecessary restraint.

Physical restraints: An ethical dilemma in mental health services in China

Given that physical restraints cause adverse effects to patients and nurses, their wide and frequent use has resulted in various clinical and ethical controversies in mental health services. The rate of physical restraints is significantly higher in China than in other countries. Some western and domestic media blamed relevant institutions for compromising the basic rights of psychiatric patients. Therefore, this study aims to collect and synthesize the relevant ethical evidence and to provide corresponding guidance for the nursing practice based on the current situation of the mainland of China. This study synthesized the ethical issue according to the ethical principle of autonomy, justice, beneficence, and non-maleficence. Given the current situation where the nursing workforce is limited and the mental health service is under-developed in China, applying physical restraints in the psychiatric inpatients to guarantee the safety of patients and nurses is crucial. In regard to respect the basic rights of psychiatric patients, it is recommended to protect the their autonomy, and eliminate the adverse effects of physical restraint. This goal would be achieved by ensuring the informed consent, providing humane care, and regulating the implementation of physical restraints.

Machine Learning: An Approach in Identifying Risk Factors for Coercion Compared to Binary Logistic Regression

Introduction: Although knowledge about negative effects of coercive measures in psychiatry exists, its prevalence is still high in clinical routine. This study aimed at define risk factors and test machine learning algorithms for their accuracy in the prediction of the risk to being subjected to coercive measures. Methods: In a sample of involuntarily hospitalized patients (n = 393) at the University Hospital of Psychiatry Zurich, we analyzed risk factors for the experience of coercion (n = 170 patients) using chi-square tests and Mann Whitney U tests. We trained machine learning algorithms [logistic regression, Supported Vector Machine (SVM), and decision trees] with these risk factors and tested obtained models for their accuracy via five-fold cross validation. To verify the results we compared them to binary logistic regression. Results: In a model with 8 risk-factors which were available at admission, the SVM algorithm identified 102 out of 170 patients, which had experienced coercion and 174 out of 223 patients without coercion (69% accuracy with 60% sensitivity and 78% specificity, AUC 0.74). In a model with 18 risk-factors, available after discharge, the logistic regression algorithm identified 121 out of 170 with and 176 out of 223 without coercion (75% accuracy, 71% sensitivity, and 79% specificity, AUC 0.82). Discussion: Incorporating both clinical and demographic variables can help to estimate the risk of experiencing coercion for psychiatric patients. This study could show that trained machine learning algorithms are comparable to binary logistic regression and can reach a good or even excellent area under the curve (AUC) in the prediction of the outcome coercion/no coercion when cross validation is used. Due to the better generalizability machine learning is a promising approach for further studies, especially when more variables are analyzed. More detailed knowledge about individual risk factors may help to prevent the occurrence of situations involving coercion.

Low Abdominal Wall Thickness May Predict Percutaneous Endoscopic Gastrostomy Complications

Although percutaneous endoscopic gastrostomy (PEG) tube placement is a common and safe procedure to provide enteral feeding, some patients develop complications. The aim of this study was to identify risk factors for the development of post-PEG complications. We hypothesized that patients with low albumin, diabetes, higher body mass index (BMI), thicker abdominal walls, or psychomotor agitation would have more complications. A 2-year retrospective review was performed on patients who received a PEG tube at a single institution. Variables collected included age, preoperative albumin, BMI, abdominal wall thickness (AWT), psychomotor agitation, pre-operative diabetes mellitus, and mortality. A total of 91 patients (70.3% male) were identified (mean age 58.7 years, SD 18.6). Seventeen patients (18.7%) had post-PEG complications and the 30-day mortality rate was 14.3 per cent. Mortality was not attributable to tube placement. Patients with complications weighed less (P = 0.005) and had a lower BMI (P = 0.010) than patients without complications. Additionally, patients with complications had significantly lower AWT (P = 0.02), mean AWT was 21.6 mm (SD 7.6) versus 27.6 mm (SD 8.1) in the noncomplication patients. AWT was the only factor independently associated with post-PEG complications (P = 0.047). There was no significant association between complications and mortality. Continued investigation on how to limit post-PEG complications remains imperative. In our population, lower AWT was independently associated with complications. Preoperative measurement of AWT by pre-procedural imaging can potentially be used to predict the risk of post-PEG complications.

Electroconvulsive therapy and its relationships with clinical characteristics and quality of life in Chinese psychiatric patients

Little is known about the pattern of electroconvulsive therapy (ECT) use in the clinical population in China. This study examined the percentage of ECT use and its association with clinical characteristics and quality of life (QOL) in a psychiatric center in China that caters for a population of 20 million. A total sample of 1364 inpatients was consecutively recruited for the study. Demographic and clinical data including the use of ECT were collected. Psychopathology, activity of daily living and QOL were measured using standardized instruments. The percentage of ECT use was 52.1% in the whole sample; 53.4% in major depression, 57.8% in bipolar disorder, 57.0% in schizophrenia and 32.4% in other diagnoses. There was no significant difference between the ECT and non-ECT groups in any domain of QOL. Multivariate analyses revealed that ECT was independently associated with the diagnoses of major depression, bipolar disorder and schizophrenia, physical restraint, severe aggression, better activity of daily living skills, more frequent use of antipsychotics and less frequent use of benzodiazepines. The percentage of ECT use was much greater in a major psychiatric center in China than those reported from other parts of the world. Use of ECT had no influence on the short-term QOL. Further investigations are warranted to explore the reasons for the high percentage of ECT use.

Physical restraint for psychiatric patients and its associations with clinical characteristics and the National Mental Health Law in China

Physical restraint (PR) for patients is an ongoing controversial topic in psychiatry. This study examined the percentage of PR and its associations with clinical characteristics and the implementation of the National Mental Health Law (NMHL) in China. The study consecutively assessed a sample of 1364 psychiatric inpatients. Socio-demographic and clinical data including use of PR were collected from the medical records using a form designed for this study and confirmed via interview. Psychopathology and insight were measured using standardized instruments. The percentage of PR was 27.2% in the whole sample with 30.7% and 22.4% occurring respectively before and after the NMHL implementation (p=0.001). In multiple logistic regression analysis PR was positively associated with unemployment, lower income, aggression in the past month, being admitted before the NMHL implementation and poorer insight. The percentage of PR in Chinese psychiatric patients is associated with various clinical factors and appeared to decrease after the implementation of the NMHL. Focused and individualized care for patients who are unemployed, have low income, recent aggression and poor insight would be necessary at early stages of admission.

Antipsychotic Medications in Major Depression and the Association with Treatment Satisfaction and Quality of Life: Findings of Three National Surveys on Use of Psychotropics in China Between 2002 and 2012

Background:

Optimizing treatment outcomes for depression requires understanding of how evidence-based treatments are utilized in clinical practice. Antipsychotic medications concurrent with antidepressant treatment are frequently used in major depression, but few studies have investigated trends and patterns of their use over time. This study aimed to examine the prescription patterns of antipsychotic medications for major depression in China from 2002 to 2012 and their association with treatment satisfaction and quality of life (QOL).

Methods:

A total of 3655 subjects with major depression treated in 45 Chinese psychiatric hospitals/centers nationwide were interviewed between 2002 and 2012. Patients’ socio-demographic and clinical characteristics including psychopathology, medication side effects, satisfaction with treatment and QOL were recorded using a standardized protocol and data collection.

Results:

The frequency of antipsychotic use was 24.9% in the whole sample; the corresponding figures were 17.1%, 20.3%, and 32.8% in 2002, 2006, and 2012, respectively (χ² = 90.3, df = 2, P < 0.001). Multiple logistic regression analyses revealed that patients on concurrent antipsychotics had significantly more delusions or hallucinations, longer illness duration, greater side effects, and more likely to be treated as inpatients and in major hospitals (i.e., Level-III hospital). Antipsychotic use was associated with lower treatment satisfaction while there was no significant difference with respect to physical and mental QOL between the antipsychotic and nonantipsychotic groups.

Conclusions:

Concurrent antipsychotic use was found in about one in four treated depressed patients in China, which has increased over a 10-year period. Considering the association of drug-induced side effects and the lack of patients’ and relatives’ satisfaction with antipsychotic treatment, further examination of the rationale and appropriateness of the use of antipsychotics in depression is needed.