Limiting Patients as a Nursing Practice in Psychiatric Intensive Care Units to Ensure Safety and Gain Control

Nurses' and Patients' Perceptions about Psychiatric Intensive Care-An Integrative Literature Review

This integrative literature review describes nurses's and patients' perceptions of care in psychiatric intensive care units (PICU). The database search was conducted in April 2020. PRISMA checklist and Mixed Method Appraisal Tool guided the identification and evaluation of the studies (n = 21). Data was analyzed with qualitative content analysis. Nurses perceived PICU as a challenging work environment where their primary task was to ensure the unit's safety. Patients views on their treatment varied from positive to negative. Patients wished to have more privacy and supportive interaction. Findings can be used as a basis in developing care practices and staff's further education in PICUs.

Mapping Healthcare Spaces: A Systematic Scoping Review of Spatial and Behavioral Observation Methods

OBJECTIVE

To provide a taxonomy of spatial observation methods that are commonly used in healthcare environments research and to describe their relative success.

BACKGROUND

Spatial observation is a valuable but resource intensive research method that is often used in healthcare environments research, but which frequently fails to deliver conclusive results. There is no existing catalog of the different spatial and behavioral observation methods that are used in healthcare design research and their benefits or limitations.

METHODS

The review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Ten key databases were searched, and articles were screened by both authors.

RESULTS

Across 67 included studies, 79 observation methods were reported. We categorized those into four, distinct methodological approaches, outlining the benefits, limitations, and suitability of each for obtaining different types of results. Common limitations included difficulty generalizing to other contexts and a lack of detailed description during data collection which led to key environment variables not being recorded. More concrete conclusions were drawn when observation methods were combined with complimentary methods such as interview.

CONCLUSIONS

The relative success of spatial observation studies is dependent on the fit of the method selected relative to the research question, approach, and healthcare setting; any complimentary methods delivered alongside it; and the analysis model employed. This article provides researchers with practical advice to guide the appropriate selection of spatial observation methods.

Coercion in psychiatric and mental health nursing: A conceptual analysis

The use of coercion in psychiatric and mental health nursing is a major challenge, which can lead to negative consequences for nurses and patients, including rupture in the therapeutic relationship and risk of injury and trauma. The concept of coercion is complex to define and is used in different ways throughout the nursing literature. This concept is defined broadly, referring to both formal (seclusion, restraint, and forced hospitalization), informal (persuasion, threat, and inducement), and perceived coercion, without fully addressing its evolving conceptualizations and use in nursing practice. We conducted a concept analysis of coercion using Rodgers' evolutionary method to identify its antecedents, attributes, and associated consequences. We identified five main attributes of the concept: different forms of coercion; the contexts in which coercion is exercised; nurses' justification of its use; the ethical issues raised by the presence of coercion; and power dynamics. Our conceptual analysis shows the need for more nursing research in the field of coercion to achieve a better understanding of the power dynamics and ethical issues that arise in the presence of coercion.

Intégration des droits humains dans la pratique du personnel infirmier faisant usage de coercition en santé mentale : recension systématique des écrits et méta-ethnographie

Introduction and background : The last decade has seen a steady and rising use of coercion in mental health care, as well as an increase in the number of forms it takes. The application of these measures frequently relies on the work of nurses, but few studies have analyzed the human rights issues raised by these practices.Aim : To produce a qualitative synthesis of how human rights are integrated into the practice of nurses who use coercion in mental health care.Methodology : A systematic review of qualitative scientific literature published between 2008 and 2018 was conducted and supplemented by a meta-ethnographic analysis.Results : The analysis of the forty-six selected studies revealed four distinct themes : coercion in mental health care as a socio-legal object, issues of recognition of human rights in mental health care, role conflict experienced by nurses, and the conceptualization of coercion as a necessary evil or a critical incident.Discussion and conclusion : Further research is needed to understand the specifics of the continuum of support and control that characterizes the coercive work of psychiatric nurses.

Experiences of acute care by persons with mental health problems: An integrative literature review

WHAT IS KNOWN ON THE SUBJECT?: Understanding experiences of acute care by persons with mental health problems is vital for improving these experiences through the development of different parts of the care delivery and its facilities. Literature has extensively addressed experiences of persons with mental health problems in acute care settings. Yet, there is a paucity of studies that aggregate and organize these findings in presenting development-oriented solutions for the improvements of these experiences. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Acute care can be understood through patients' experiences of structure (such as setting, staff and resources); process (such as communication and interpersonal relations); and outcome (such as satisfaction and post-discharge well-being and health) and suggests improvements in these domains. The paper illuminates that previous literature has mainly captured negative experiences of acute care by persons with mental health problems, and suggests diverting the focus to the best practices and to seek inspiration from other fields of research. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Attending to the improvement and development of different parts of the acute care might be an important step in improving experiences of persons with mental health problems. For example, improving resource allocation systems and facilities, emphasizing professionalism in encounters with these patients and systematically assessing patient satisfaction during and after visits are important areas that require attention. ABSTRACT: Aim The provision of acute care to persons with mental health problems is challenging due to difficulties in encountering this group and the vulnerability of these persons. Understanding this group's experiences with acute care is thus an important endeavour. The purpose of this review was to critically and systematically identify and assess previous research on experiences of acute care by persons with mental health problems, guided by Donabedian's structure-process-outcome framework (Prospero ID: CRD42019116652). Method and results An integrative literature review was performed, resulting in the identification of 43 studies. The search was conducted using five electronic databases: Web of Science Core, PubMed, MEDLINE, CINAHL and PsycINFO. Discussion The review revealed that patients experienced structure components such as setting, staff and resources in a predominantly negative way. A predominately negative picture also emerged of the process components, where, for example, communication and interpersonal relations were represented by negative experiences, with limited positive experiences reported. The outcome components, related to patients' satisfaction and their well-being after discharge, were also predominantly experienced negatively. Implications for practice Using Donabedian's framework of structure, process and outcome allowed us to systematize the literature reviewed, to identify the research gaps and to suggest ways forward for the field's development.

Bucking the system: Mitigating psychiatric patient rule breaking for a safer milieu

This article examines patients' understandings of rule breaking in the hospital setting. This work is important to inpatient psychiatric nursing because considering patients' perspectives about their own rule breaking can help nurses provide more therapeutic and safer patient care. The study finds that rule breaking behaviors are often a manifestation of patient resistance to institutionalization and loss of power. These behaviors are also related to nursing practice, as patients closely observe staff and look for gaps in the system to get away with or circumvent the rules. These findings suggest rule breaking behaviors can be reduced not by trying to further curtail the patient's autonomy but, rather, by changing the rules and/or how they are administered by staff to accommodate patients' perspectives and needs for freedom. Also, nurses must be clear in communicating with patients about the rationale for rules, and be consistent in how they enforce them.

Healing architecture and psychiatric practice: (re)ordering work and space in an in-patient ward in Denmark

Healing architecture is a defining feature of contemporary hospital design in many parts of the world, with psychiatric in-patient facilities in Denmark at the forefront of this innovation. The approach rests on the contention that designed clinical spaces and the particular dispositions they express may promote patient recovery. Although the idea that health may be spatially mediated is well-established, the means of this mediation are far from settled. This article contributes to this debate by analysing medical encounters in the context of a new purpose-built psychiatric hospital opened in Slagelse, Denmark in late 2015 as an example of healing architecture for the region. Grounded in qualitative research conducted in two wards between 2016 and 2017, we explore the key material and social effects of the hospital's healing architecture, and the spaces and practices it enacts. Following the work of Michael Lynch, we consider both the designed 'spatial order' of the in-patient wards and the 'spatial orderings' unfolding therein with a particular interest in how order is accomplished in psychiatric work. With much of the existing discussion of healing architectures focusing on their impacts on patient wellbeing, we consider how healing architectures may also be transforming psychiatric work.

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.

Moral mindfulness: The ethical concerns of healthcare professionals working in a psychiatric intensive care unit

Healthcare professionals working on inpatient wards face the externalizing or challenging behaviour of the patients who are admitted. Ethical values and principles in psychiatric nursing have been reported to be important when approaching patients during the most acute phase of deterioration in their mental health. Hence, the aim of this study was to discover and describe staff members' ethical and moral concerns about their work as healthcare professionals in a psychiatric intensive care unit. The study has a qualitative descriptive design and makes use of Framework Analysis. Registered nurses and psychiatric aides in a psychiatric intensive care unit in Sweden were observed during ethical reflection meetings. Four to six staff attended the 90-min meetings. The data comprise observations from six meetings, which provided 94 pages of text. The results demonstrate that the work was described as being both motivating and exhausting. The staff faced ethical concerns in their daily work, as patients often demonstrated challenging behaviours. Three themes were identified as follows: (i) concerns about the staff impacting on patients' experience of care, (ii) concerns about establishing a safe working environment, and (iii) concerns about becoming unprofessional due to expectations and a high workload. Ethical concerns included simultaneously taking into account both the patients' dignity and safety aspects, while also being exposed to high workloads. These elements of work are theorized as influencing complex psychiatric nursing. If we are to bring these influential factors to light in the workplace, advanced nursing practice must be grounded in moral mindfulness.

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.

Using Participatory Action Research to Develop a Working Model That Enhances Psychiatric Nurses' Professionalism: The Architecture of Stability

Ward rules in psychiatric care aim to promote safety for both patients and staff. Simultaneously, ward rules are associated with increased patient violence, leading to neither a safe work environment nor a safe caring environment. Although ward rules are routinely used, few studies have explicitly accounted for their impact. To describe the process of a team development project considering ward rule issues, and to develop a working model to empower staff in their daily in-patient psychiatric nursing practices. The design of this study is explorative and descriptive. Participatory action research methodology was applied to understand ward rules. Data consists of audio-recorded group discussions, observations and field notes, together creating a data set of 556 text pages. More than 100 specific ward rules were identified. In this process, the word rules was relinquished in favor of adopting the term principles, since rules are inconsistent with a caring ideology. A linguistic transition led to the development of a framework embracing the (1) Principle of Safety, (2) Principle of Structure and (3) Principle of Interplay. The principles were linked to normative guidelines and applied ethical theories: deontology, consequentialism and ethics of care. The work model reminded staff about the principles, empowered their professional decision-making, decreased collegial conflicts because of increased acceptance for individual decisions, and, in general, improved well-being at work. Furthermore, the work model also empowered staff to find support for their decisions based on principles that are grounded in the ethics of totality.

Being Subject to Restrictions, Limitations and Disciplining: A Thematic Analysis of Individuals' Experiences in Psychiatric Intensive Care

The aim of this study was to describe individuals' experiences of being hospitalized in psychiatric intensive care units (PICUs). Four participants who had previously been admitted in a PICU were interviewed using open-ended questions. The data were analyzed using thematic analysis. Analysis resulted in a synthesis of the various ways patients experienced limitations: (1) Descriptions of Being Limited in the Environment, (2) Descriptions of being Limited in Interactions with Staff, (3) Descriptions of Being Limited in terms of Access to Information, and (4) Descriptions of Having Limited Freedom and Autonomy. Hospitalization is experienced as a life-changing event that shows a kaleidoscopic view of limitation. We stress that the conceptualization of limitation must be considered due to its historical origins, sociopolitical aspirations, and philosophy of care. Thus, nurse practitioners and nursing leaders are advised to put the patient's experience at the center of care, and to involve and integrate patients throughout the recovery process.

Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice

The discourse of safety has informed the care of individuals with mental illness through institutionalization and into modern psychiatric nursing practices. Confinement arose from safety: out of both societal stigma and fear for public safety, as well as benevolently paternalistic aims to protect individuals from self‐harm. In this paper, we argue that within current psychiatric inpatient environments, safety is maintained as the predominant value, and risk management is the cornerstone of nursing care. Practices that accord with this value are legitimized and perpetuated through the safety discourse, despite evidence refuting their efficacy, and patient perspectives demonstrating harm. To illustrate this growing concern in mental health nursing care, we provide four exemplars of risk management strategies utilized in psychiatric inpatient settings: close observations, seclusion, door locking and defensive nursing practice. The use of these strategies demonstrates the necessity to shift perspectives on safety and risk in nursing care. We suggest that to re‐centre meaningful support and treatment of clients, nurses should provide individualized, flexible care that incorporates safety measures while also fundamentally re‐evaluating the risk management culture that gives rise to and legitimizes harmful practices.