Pilot study of a sensory room in an acute inpatient psychiatric unit

Uncovering Complexities in Reducing Aggression, Conflict and Restrictive Practices in Acute Mental Healthcare Settings: An Overview of Reviews

Aggression, conflict and restrictive practices present complexities in acute mental health services, as do implementing service changes to reduce them. Existing published literature needs to offer more high-level guidance on the effectiveness of these service changes and their associated implementation factors. As a result, an overview of systematic reviews was undertaken to identify (i) nonpharmacological interventions to reduce conflict, aggression and restrictive practices in acute mental health settings, and (ii) their effects across different clinical outcomes. A parallel re-extraction from primary studies was then utilised (iii) to identify factors influencing successful intervention implementation. Of 124 articles sourced from nine databases and registries, four reviews were retained for the final analysis, using the direction of effect and tabular and narrative summaries. These reviews included programmes or interventions focused on inpatient adolescent, adult and older adult populations. They reported on alternative containment strategies, risk assessments, Safewards, sensory rooms and equipment, Six Core Strategy-based interventions and staff training. The overview found that a combination of interventions intended to improve relationships and reduce interpersonal conflict may help reduce aggression, conflict and restrictive practices. At the same time, stand-alone staff training and sensory rooms and equipment may have mixed effects. The quality of the evidence linking these interventions to reductions in aggression, conflict and restrictive practices is limited. Successful implementation hinges on multiple factors: intervention characteristics, preparation and planning, evaluation and monitoring, outcome interpretation, stakeholder involvement/investment, staff-related factors and contextual factors. Any implementation initiative may benefit from using pragmatic and complexity-informed research methodologies, including integrating meaningful involvement with service users, peer workers and culturally diverse groups.

The Impact of Sensory Modulation Interventions on Practice in Acute Inpatient Mental Health Settings: A Meta-Ethnography

This review explores the transformative impact of sensory modulation interventions in acute inpatient mental health care setting utilising meta-ethnography. The methodology by Noblit & Hare guided the approach to creating the review. Searches of articles published within the previous 10 years were conducted in Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE, and PsycINFO. Searches aimed to identify rich qualitative data on the area of sensory modulation interventions and acute inpatient mental health care. Seven articles were selected for inclusion and a reciprocal translation synthesis was undertaken. Sensory modulation interventions emerged as a key alternative to traditional inpatient practices, including seclusion and restraint and the use of PRN psychotropic medication. It introduces a new dimension within care strategies that emphasise individual preferences and care plans that empower individuals. Sensory modulation interventions serve as an effective means to de-escalation that promotes shared responsibility between staff and individuals in care. The review highlights this practice as a departure from coercive practices and biomedical interventions, promoting meaningful therapeutic engagement. Our findings show that sensory modulation interventions have the potential to create a culture shift in acute inpatient mental health settings towards person-centred, recovery-orientated, trauma-informed clinical practice.

Protocols to reduce seclusion in inpatient mental health units

The use of seclusion to manage conflict behaviours in psychiatric inpatient settings is increasingly viewed as an intervention of last resort. Many protocols have, thus, been developed to reduce the practice. We conducted a systematic review to determine the effectiveness of protocols to reduce seclusion on process outcomes (e.g., seclusion, restraint), patient outcomes (e.g., injuries, aggressive incidents, satisfaction), and staff outcomes (e.g., injuries, satisfaction). We searched Medline, Embase, the Cochrane Register of Clinical Trials, PsycINFO, CINAHL, cairn.info, and ClinicalTrials.gov for protocols to reduce seclusion practices for adult patients on inpatient mental health units (from inception to September 6, 2022). We summarised and categorised reported elements of the protocols designed to reduce seclusion using the Behaviour Change Wheel Intervention Functions and resources needed to implement the protocol in psychiatric units. We assessed risk of bias and determined certainty of evidence using GRADE. Forty-eight reports addressed five approaches to reduce seclusion: hospital/unit restructuring (N = 4), staff education/training (N = 3), sensory modulation rooms (N = 7), risk assessment and management protocols (N = 7), and comprehensive/mixed interventions (N = 22; N = 6 without empirical data). The relationship between the various protocols and outcomes was mixed. Psychiatric units that implement architecturally positive designs, sensory rooms, the Brøset Violence Checklist, and various multi-component comprehensive interventions may reduce seclusion events, though our certainty in these findings is low due to studies' methodological limitations. Future research and practice may benefit from standardised reporting of process and outcome measures and analyses that account for confounders.

The effectiveness of brief non-pharmacological interventions in emergency departments and psychiatric inpatient units for people in crisis: A systematic review and narrative synthesis

OBJECTIVE

Heterogeneous brief non-pharmacological interventions and guidelines exist to treat the burgeoning presentations to both emergency department and inpatient settings, for those in a crisis of mental ill-health. We systematically reviewed the literature to create a taxonomy of these brief non-pharmacological interventions, and review their evaluation methods and effectiveness.

METHOD

We conducted a systematic review across Cochrane, CINAHL, DARE, Embase, MEDLINE, PsycINFO databases. Studies meeting quality criteria, using Joanna Briggs Institute tools, were eligible. Interventions were categorised, and outcomes synthesised.

RESULTS

Thirty-nine studies were included: 8 randomised controlled trials, 17 quasi-experimental, 11 qualitative studies, and 3 file audits. Taxonomy produced six coherent intervention types: Skills-focussed, Environment-focussed, Special Observation, Psychoeducation, Multicomponent Group and Multicomponent Individual. Despite this, a broad and inconsistent range of outcome measures reflected different outcome priorities and prevented systematic comparison of different types of intervention or meta-analysis. Few brief non-pharmacological interventions had consistent evidential support: sensory modulation rooms consistently improved distress in inpatient settings. Short admissions may reduce suicide attempts and readmission, if accompanied by psychotherapy. Suicide-specific interventions in emergency departments may improve depressive symptoms, but not suicide attempt rates. There was evidence that brief non-pharmacological interventions did not reduce incidence of self-harm on inpatient wards. We found no evidence for frequently used interventions such as no-suicide contracting, special observation or inpatient self-harm interventions.

CONCLUSION

Categorising brief non-pharmacological interventions is feasible, but an evidence base for many is severely limited if not missing. Even when there is evidence, the inconsistency in outcomes often precludes clinicians from making inferences, although some interventions show promise.

Patient experience of a virtual reality calm room in a psychiatric inpatient care setting in Sweden: a qualitative study with inpatients

OBJECTIVE

Calm rooms have been developed and implemented in psychiatric inpatient care settings to offer patients a dedicated space for relaxation in a convenient and safe environment. Recent technology developments have enabled virtual reality (VR) equivalents of calm rooms that can be feasibly deployed in psychiatric care settings. While research has shown VR environments to be efficacious in inducing relaxation, little is known how these virtual calm rooms are perceived by patients. The aim of this study was to elucidate patient experiences of using a VR calm room in a psychiatric inpatient setting.

DESIGN

Qualitative interview study. Semi-structured interviews were analysed using qualitive inductive content analysis, which focuses on the interpretation of texts for making replicable and valid inferences.

SETTING

Swedish hospital psychiatric inpatient care setting with a wireless, three degrees-of-freedom VR head-mounted display running a calm room application simulating nature environment.

PARTICIPANTS

20 adult patients (12 women) with bipolar disorder (n=18) or unipolar depression (n=2).

RESULTS

Participants experienced the use of the VR calm room as having a positive impact on them, inducing awareness, calmness and well-being. They were thankful to be offered a non-pharmacological alternative for anxiety relief. Participants also expressed that they had some concerns about how they would react emotionally before using the VR device. However, after use, they highlighted that their overall experience was positive. They also expressed that they could see potential for further development of VR technology in psychiatric care.

CONCLUSIONS

VR technology has the potential to solve pressing logistic issues in offering calm rooms in psychiatric inpatient care. VR calm rooms appear to be appreciated by psychiatric inpatients, who value their accessibility, convenience and variety of modalities offered. Participants perceived an increase in their well-being after use.

An Integrative Review on Psychiatric Intensive Care

Psychiatric intensive care units (PICUs) provide care and treatment when psychiatric symptoms and behaviors exceed general inpatient resources. This integrative review aimed to synthesize PICU research published over the past 5 years. A comprehensive search in MEDLINE, PsycINFO, PubMed and Scopus identified 47 recent articles on PICU care delivery, populations, environments, and models. Research continues describing patient demographics, and high rates of challenging behaviors, self-harm, and aggression continue being reported. Research on relatives was minimal. Patients describe restrictive practices incongruent with recovery philosophies, including controlling approaches and sensory deprivation. Some initiatives promote greater patient autonomy and responsibility in shaping recovery, yet full emancipatory integration remains limited within PICU environments. Multidisciplinary collaboration is needed to holistically advance patient-centered, equitable, and integrative PICU care. This review reveals the complex tensions between clinical risk management and emancipatory values in contemporary PICU settings. Ongoing reporting of controlling practices counters the recovery movement progressing in wider mental healthcare contexts. However, care innovations centered on patient empowerment and humane environments provide hope for continued evolution toward more liberation-focused PICU approaches that uphold both patient and provider perspectives.

Exploring the content of self-help toolkits as an intervention for non-suicidal self-injury in young people in England

Non-suicidal self-harm has been increasing in young people over the last decade leading to several self-help interventions being developed. Self-help toolkits are given a variety of names, such as 'hope box' and 'self-soothe kit', but all seek to provide young people with the tools to manage thoughts to self-harm by bringing together a collection of personal items, distress tolerance activities and help-seeking prompts. They represent a low-cost, low-burden and accessible intervention. This study explored what child and adolescent mental health professionals working with young people are currently recommending as the content of these self-help toolkits. A questionnaire was sent to child and adolescent mental health services and residential units across England and received 251 responses from professionals. Sixty-six per cent described self-help tool kits as being effective or very effective for helping young people manage self-harm urges. The content was categorized into sensory items (subcategorized by sense), distraction activities, relaxation and mindfulness activities, seeking positives and coping strategies, with the caveat that all toolkits should be individualized. The results of this study help to inform the future manualization of the use of self-help toolkits in clinical practice as a self-harm intervention for children and young people.

Planning for Change: Co-Designing Implementation Strategies to Improve the Use of Sensory Approaches in an Acute Psychiatric Unit

Implementing sensory approaches in psychiatric units has proven challenging. This multi-staged study involved qualitative interviews (n = 7) with mental health care staff in an acute psychiatric ward to identify the local factors influencing use of sensory approaches, and co-design implementation strategies with key stakeholders to improve their use. Using framework analysis, results revealed that the use of sensory approaches were hindered by: inadequate access to sensory resources/equipment; lack of time; lack of staff knowledge; and belief that sensory approaches are not effective or part of staff's role. To address identified barriers a systematic theory-informed method was used to co-design implementation strategies to improve the use of sensory approaches.

The Use of Alternative Rooms in Forensic and Regular Psychiatric Units: A Scoping Review

(1) Background: Emotional regulation, distress and relational conflicts often occur during hospitalization and rehabilitation on psychiatric units, especially in patients suffering from severe and persistent mental disorders. While widely used in children and geriatric patients, little literature exists on the use and outcomes of alternative rooms in the context of forensic and regular psychiatric units for adult patients. Considering the scarcity of the literature on alternative use, this study is motivated by the following research question: what are the main uses and outcomes of alternative rooms in the context of forensic and regular psychiatric units? The main objective of this study is to conduct a scoping review of the use and outcomes of alternative rooms for the context of psychiatric inpatients. (2) Methods: A systematic search was performed in the electronic databases of MedLine, Web of Science, PsycNet (PsycINFO) and Google Scholar from their inception dates until 2022. (3) Results: A total of nine studies were analyzed. Sensory, multisensory rooms, Snoezelen, and comfort rooms are the types of alternative rooms discussed in these studies. Distress and anxiety reduction, increase in self-esteem, impact on seclusion rates, patient-staff communication and alliances, heart and respiration rate reduction, and improvement of alexithymia were identified among the main uses and outcomes of these rooms. (4) Conclusions: The scarcity of literature available to draw information from for this review and possible impact on improving patient outcomes and quality of treatment in psychiatric units opens the door to future studies to better understand the efficacy of such rooms. Research into the ideal implementation tactics of such rooms, long-term outcomes, and the influence on diverse patient demographics could be areas of improvement in the use of alternative rooms.

[Soothing spaces and techniques in psychiatry]

The development of alternatives to seclusion and restraint is a priority for psychiatric care services. Among them, the implementation of soothing spaces is currently experiencing considerable growth.

Use of sensory rooms in adult psychiatric inpatient settings: A systematic review and narrative synthesis

Reducing the use of restrictive interventions within psychiatric inpatient settings is a global priority. There are many strategies which may support the prevention of violence before escalation into more severe incidences. Sensory rooms have been identified as one such intervention, aiding patients to emotionally regulate and reduce distress, with a growing body of academic literature interested in whether sensory rooms can ultimately impact incidences of patient violence and the use of restraint, seclusion, and other restrictive practices. A systematic literature review was conducted to identify how effective sensory rooms are at reducing patient violence and restrictive interventions within adult psychiatric inpatient settings. Eighteen studies met the eligibility criteria and were included in the review. There is a lack of evidence as to whether sensory rooms are effective at reducing seclusion, restraint, or violence. They are, however, likely to support a reduction in patient distress. Patient and staff experiences suggest sensory rooms support emotional regulation, promote self-management, and positively impact the overall patient admission experience and ward environment. Further research is needed to identify what works, for who and in what circumstances in relation to the design of sensory rooms.

Sensory approaches in psychiatric units: Patterns and influences of use in one Australian health region

BACKGROUND/AIM

Australian guidelines and policies recommend the use of sensory approaches in mental health care. Nevertheless, many Australian psychiatric units report difficulty sustaining these approaches. To inform efforts to close the gap between recommendations and practice, the aim of this study was to understand the patterns of use of sensory approaches and what demographic and clinical factors influence their use, across one health region in Queensland, Australia.

METHODS

Using a cross-sectional survey design, a custom-designed questionnaire was distributed via email and in paper form to health professionals and peer support workers working in acute, secure, and community care psychiatric units across one health region. Information on demographics and the use of various sensory interventions was gathered utilising both open-ended and Likert scale questions.

RESULTS

Useable questionnaires were collected from 183 participants from various disciplines (77% nursing). The majority reported using sensory approaches with a limited number of consumers, and almost 9% never used the approach. Activity-based sensory interventions and sensory equipment were most often used, whereas sensory assessments, sensory plans, and sensory groups were least used. Sensory interventions were mainly used to reduce consumer anxiety and agitation and to assist with emotional regulation. Factors positively correlated with frequency of use for all interventions were discipline (occupational therapy); working in an acute inpatient unit; and training in sensory approaches. Age was negatively correlated with frequency of use only for weighted modalities.

CONCLUSIONS

This study revealed that sensory approaches were used by most staff though with a limited proportion of consumers in psychiatric units in one large metropolitan health service. It provides insights into the factors influencing frequency of use, highlighting the importance of training in sensory approaches and access to occupational therapists. With this knowledge, we can work towards closing the gap between recommendations and the practice of sensory approaches.

Changes in emotions and perceived stress following time spent in an artistically designed multisensory environment

Self-management strategies that enhance positive emotions are considered most effective to cope with stress and maintain good mental health and well-being. An artistically designed multisensory environment, The Sensory-Art Space (SAS), was installed in a university in NSW Australia as a new self-management intervention. The design of the SAS was informed by evidence regarding the benefits of viewing art, experiencing nature and accessing sensory rooms.A pilot pre-post intervention study measured changes in affect and perceived stress in 224 participants who spent time in the SAS. Descriptive statistics were completed on the individual affective states, and paired sample t-tests were used to determine changes in Positive and Negative Affect (PANAS-X) and perceived stress (Visual Analogue Scale).The Wilcoxon signed-rank test showed that negative affect reduced, z=-10.23 (p<0.001), and positiveaffect increased, z=-2.57 (p=0.01), following spending time in the SAS. In addition, stress levels reduced after time spent in the SAS, z=-11.29 (p<0.0001).Self-management benefits were found following time in the SAS and future implications for public health and well-being are discussed.

It's Not Just in the Walls: Patient and Staff Experiences of a New Spatial Design for Psychiatric Inpatient Care

The environment in psychiatric inpatient care is key to patient recovery and staff job satisfaction. In this qualitative study of patient and staff experiences of a new spatial design in psychiatric inpatient care, we analysed data from 11 semi-structured interviews with patients and five focus group discussions with staff using qualitative content analysis. The new design contributed to feelings of safety and recovery, but patients and staff also reported some frustration and added stress. The results lead us to conclude that while the new spatial design improves some conditions for recovery and job satisfaction, the design itself is simply not enough. Changes in care environments require that both patients and staff be informed and involved in the renovation to ensure that patients feel respected and staff feel confident in using the new environment before and during treatment and follow-ups.

Design features that reduce the use of seclusion and restraint in mental health facilities: a rapid systematic review

Increasing efforts are being made to prevent and/or eliminate the use of seclusion and restraint in mental health facilities. Recent literature recognises the importance of the physical environment in supporting better outcomes in mental health services. This rapid review scoped the existing literature studying what physical design features of mental health facilities can reduce the use of seclusion and physical restraint.

DESIGN

A rapid review of peer-reviewed literature.

METHODS

Peer-reviewed literature was searched for studies on architectural design and the use of restraint and seclusion in mental health facilities. The following academic databases were searched: Cochrane Library, Medline, PsycINFO, Scopus and Avery for English language literature published between January 2010 and August 2019. The Joanna Briggs Institute's critical appraisal tool was used to assess the quality of included studies.

RESULTS

We identified 35 peer-reviewed studies. The findings revealed several overarching themes in design efforts to reduce the use of seclusion and restraint: a beneficial physical environment (eg, access to gardens or recreational facilities); sensory or comfort rooms; and private, uncrowded and calm spaces. The critical appraisal indicated that the overall quality of studies was low, as such the findings should be interpreted with caution.

CONCLUSION

This study found preliminary evidence that the physical environment has a role in supporting the reduction in the use of seclusion and restraint. This is likely to be achieved through a multilayered approach, founded on good design features and building towards specific design features which may reduce occurrences of seclusion and restraint. Future designs should include consumers in a codesign process to maximise the potential for change and innovation that is genuinely guided by the insights of lived experience expertise.

Sensory-based approaches in psychiatric care: A systematic mixed-methods review

AIMS

Sensory-based approaches, including sensory room, sensory cart and specific sensory integration programs, feature various sensory stimulations to focus on a particular space or program. This systematic mixed-methods review describes the impact of sensory-based approaches in psychiatric care and summarizes the important components of sensory interventions.

DESIGN

Systematic mixed-methods review was based on the guidelines by Pluye and Hong for comprehensively searching, appraising and synthesizing research evidence.

DATA SOURCES

Data were collected from five databases: CINAHL, Embase, Pubmed, Web of Science and Cochrane before March 9, 2020.

REVIEW METHODS

Qualitative, quantitative, mixed-methods and original studies published in English on sensory-based approaches in psychiatric care were included. The studies were selected by screening titles, abstracts and full texts, and the quality of each study was assessed by two researchers independently. The data were analysed using thematic analysis.

RESULTS

Sixteen studies were chosen for review. Through data integration, four subthemes with positive effects were formed: (1) calming of the patient's mood; (2) calming of the patient's body; (3) improvement of self-care ability; and (4) improvement of the nurse-patient relationship. The sensory-based approach may also lead to negative effects.

CONCLUSIONS

Several important components play important roles in the sensory-based approaches: (1) rich, culture-based, personalized sensory stimulation; (2) a quiet, safe, home-based physical environment; (3) a good one-to-one nurse-patient relationship; (4) and the cultivation of patient autonomy and self-management. Sensory-based approaches in a multicultural environment and home environment will be important topics of psychiatric care in the future.

IMPACT

There is a lack of synthesis of studies on results of sensory-based approaches in psychiatric care. Four components are important to sensory interventions. It is necessary for mental health service centres and home care for the patients with psychotic disorders to use sensory-based approaches for reference.

Views about sensory modulation from people with schizophrenia and treating staff: A multisite qualitative study

Introduction

Current non-pharmacological treatment options for people with schizophrenia are limited. There is, however, emerging evidence that sensory modulation can be beneficial for this population. This study aimed to gain insight into sensory modulation from the user’s and the treating staff’s perspectives.

Method

A qualitative content analysis design was used. Transcripts from occupational therapists ( n=11) and patients with schizophrenia ( n=13) derived from in-depth semi-structured interviews were analysed for themes using content analysis.

Results

Five themes emerged from this study: Service user education on the sensory approach is the key; A variety of tools should be tried; Sensory modulation provides a valued treatment option; There are challenges of managing perceived risk at an organisational level; and There is a shortage of accessible and effective training.

Conclusion

People with schizophrenia and treating staff had congruent perceptions regarding the use of sensory modulation as a treatment option. The findings suggest that sensory modulation can be a valued addition to treatment options for people with schizophrenia. We suggest further research on sensory modulation intervention effectiveness using quantitative methods so these results can be further explored.

Non-pharmacological interventions to reduce restrictive practices in adult mental health inpatient settings: the COMPARE systematic mapping review

Objectives

The study aimed to provide a mapping review of non-pharmacological interventions to reduce restrictive practices in adult mental health inpatient settings; classify intervention components using the behaviour change technique taxonomy; explore evidence of behaviour change techniques and interventions; and identify the behaviour change techniques that show most effectiveness and those that require further testing.

Background

Incidents involving violence and aggression occur frequently in adult mental health inpatient settings. They often result in restrictive practices such as restraint and seclusion. These practices carry significant risks, including physical and psychological harm to service users and staff, and costs to the NHS. A number of interventions aim to reduce the use of restrictive practices by using behaviour change techniques to modify practice. Some interventions have been evaluated, but effectiveness research is hampered by limited attention to the specific components. The behaviour change technique taxonomy provides a common language with which to specify intervention content.

Design

Systematic mapping study and analysis.

Data sources

English-language health and social care research databases, and grey literature, including social media. The databases searched included British Nursing Index (BNI), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CCRCT), Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE), EMBASE, Health Technology Assessment (HTA) Database, HTA Canadian and International, Ovid MEDLINE®, NHS Economic Evaluation Database (NHS EED), PsycInfo®and PubMed. Databases were searched from 1999 to 2019.

Review methods

Broad literature search; identification, description and classification of interventions using the behaviour change technique taxonomy; and quality appraisal of reports. Records of interventions to reduce any form of restrictive practice used with adults in mental health services were retrieved and subject to scrutiny of content, to identify interventions; quality appraisal, using the Mixed Methods Appraisal Tool; and data extraction, regarding whether participants were staff or service users, number of participants, study setting, intervention type, procedures and fidelity. The resulting data set for extraction was guided by the Workgroup for Intervention Development and Evaluation Research, Cochrane and theory coding scheme recommendations. The behaviour change technique taxonomy was applied systematically to each identified intervention. Intervention data were examined for overarching patterns, range and frequency. Overall percentages of behaviour change techniques by behaviour change technique cluster were reported. Procedures used within interventions, for example staff training, were described using the behaviour change technique taxonomy.

Results

The final data set comprised 221 records reporting 150 interventions, 109 of which had been evaluated. The most common evaluation approach was a non-randomised design. There were six randomised controlled trials. Behaviour change techniques from 14 out of a possible 16 clusters were detected. Behaviour change techniques found in the interventions were most likely to be those that demonstrated statistically significant effects. The most common intervention target was seclusion and restraint reduction. The most common strategy was staff training. Over two-thirds of the behaviour change techniques mapped onto four clusters, that is ‘goals and planning’, ‘antecedents’, ‘shaping knowledge’ and ‘feedback and monitoring’. The number of behaviour change techniques identified per intervention ranged from 1 to 33 (mean 8 techniques).

Limitations

Many interventions were poorly described and might have contained additional behaviour change techniques that were not detected. The finding that the evidence was weak restricted the study’s scope for examining behaviour change technique effectiveness. The literature search was restricted to English-language records.

Conclusions

Studies on interventions to reduce restrictive practices appear to be diverse and poor. Interventions tend to contain multiple procedures delivered in multiple ways.

Future work

Prior to future commissioning decisions, further research to enhance the evidence base could help address the urgent need for effective strategies. Testing individual procedures, for example, audit and feedback, could ascertain which are the most effective intervention components. Separate testing of individual components could improve understanding of content and delivery.

Study registration

The study is registered as PROSPERO CRD42018086985.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 9, No. 5. See the NIHR Journals Library website for further project information.

Measures to Avoid Coercion in Psychiatry and Their Efficacy

BACKGROUND

Coercive measures such as seclusion and restraint encroach on the patient's human rights and can have serious adverse effects ranging from emotional trauma to physical injury and even death. At the same time, they may be the only way to avert acute danger for the patient and/or the hospital staff. In this article, we provide an overview of the efficacy of the measures that have been studied to date for the avoidance of coercion in psychiatry.

METHODS

This review is based on publications retrieved by a systematic search in the Medline and Cinahl databases, supplemented by a search in the reference lists of these publications. We provide a narrative synthesis in which we categorize the interventions by content.

RESULTS

Of the 84 studies included in this review, 16 had a control group; 6 of these 16 were randomized controlled trials (RCTs). The interventions were categorized by seven different types of content: organization, staff training, risk assessment, environment, psychotherapy, debriefings, and advance directives. Most interventions in each category were found to be effective in the respective studies. 38 studies investigated complex treatment programs that incorporated elements from more than one category; 37 of these (including one RCT) revealed effective reduction of the frequency of coercion. Two RCTs on the use of rating instruments to assess the risk of aggressive behavior revealed a relative reduction of the number of seclusion measures by 27% and a reduction of the cumulative duration of seclusion by 45%.

CONCLUSION

Complex intervention programs to avoid coercive measures, incorporating elements of more than one of the above categories, seem to be particularly effective. In future, cluster-randomized trials to investigate the individual categories of intervention would be desirable.

Health provider and service-user experiences of sensory modulation rooms in an acute inpatient psychiatry setting

BACKGROUND

Sensory modulation rooms (SMRs) are therapeutic spaces that use sensory modulation concepts and strategies to assist service users to self-regulate and modulate arousal levels. SMRs are increasingly being explored as strength-based and person-centered adjuncts to care for people receiving inpatient psychiatry services. The aim of this study is to understand health provider and inpatient service user perceptions on the use of SMRs on acute psychiatric units.

METHODS

We conducted semi-structured interviews with ten service users and nine health providers (four occupational therapists and five nurses) regarding their experiences of the SMRs located on three acute inpatient units in a large urban tertiary care hospital. We audio recorded and transcribed the focus groups and used thematic analysis to analyze the data.

RESULTS

Our results suggested four common themes amongst health provider and service user experiences of sensory modulation rooms: (1) service user empowerment through self-management, (2) emotional regulation, (3) an alternative to current practices, and (4) health provider and service user education.

CONCLUSION

Our study supports the ecological utility of SMRs as person-centred adjunct therapeutic space viewed positively by both service users and health providers. This understanding of SMRs is critical for future service design, research and policy aimed at improving the service user experience and care for this population. Future research is needed to validate the experience of the SMRs with other patient groups and health providers.

The experiences of patients in using sensory rooms in psychiatric inpatient care

The use of sensory rooms and similar sensory approaches in psychiatric inpatient settings is becoming increasingly common. In sensory rooms, patients can choose different sensory stimulating items that may help regulate distress and enhance well-being. Outcomes are often measured as effects on patients' self-rated distress and rates of seclusion and restraint. The subjective experiences of patients using sensory rooms have been less explored. This paper presents a qualitative study of the experiences of 28 patients who chose to use sensory rooms on seven different types of psychiatric inpatient wards. Data were collected by individual patient interviews and by texts written by patients. A qualitative content analysis resulted in four categories: emotional calm, bodily calm, empowerment, and unexpected effects. A majority of the participants described several positive experiences, such as enhanced well-being, reduced anxiety, increased self-management, and enhanced self-esteem. Our findings align with previous research that has shown similar positive patient experiences, and support the use of sensory rooms as part of person-centred care.

Consumer Perspectives of Safewards Impact in Acute Inpatient Mental Health Wards in Victoria, Australia

Background: Inpatient mental health wards are reported by many consumers to be custodial, unsafe, and lacking in therapeutic relationships. These consumer experiences are concerning, given international policy directives requiring recovery-oriented practice. Safewards is both a model and a suite of interventions designed to improve safety for consumers and staff. Positive results in reducing seclusion have been reported. However, the voice of consumers has been absent from the literature regarding Safewards in practice. Aim: To describe the impact of Safewards on consumer experiences of inpatient mental health services. Method: A postintervention survey was conducted with 72 consumers in 10 inpatient mental health wards 9-12 months after Safewards was implemented. Results: Quantitative data showed that participants felt more positive about their experience of an inpatient unit, safer, and more connected with nursing staff. Participants reported that the impact of verbal and physical aggression had reduced because of Safewards. Qualitatively, participants reported increased respect, hope, sense of community, and safety and reduced feelings of isolation. Some participants raised concerns about the language and intention of some interventions being condescending. Discussion: Consumers' responses to Safewards were positive, highlighting numerous improvements of importance to consumers since its implementation across a range of ward types. The findings suggest that Safewards offers a pathway to reducing restrictive interventions and enables a move toward recovery-oriented practice.

Using interventions to reduce seclusion and mechanical restraint use in adult psychiatric units: an integrative review

The aim of this integrative review was to describe interventions aimed at reducing seclusion and mechanical restraint use in adult psychiatric inpatient units and their possible outcomes. CINAHL, MEDLINE, PsycINFO and Medic databases were searched for studies published between 2008 and 2017. Based on electronic and manual searches, 28 studies were included, and quality appraisal was carried out. Data were analysed using inductive content analysis. Interventions to proactively address seclusion were environmental interventions, staff training, treatment planning, use of information and risk assessment. Interventions to respond to seclusion risk were patient involvement, family involvement, meaningful activities, sensory modulation and interventions to manage patient agitation. Interventions to proactively address mechanical restraint were mechanical restraint regulations, a therapeutic atmosphere, staff training, treatment planning and review of mechanical restraint risks. Interventions to respond to mechanical restraint risks included patient involvement, therapeutic activities, sensory modulation and interventions to manage agitation. Outcomes related to both seclusion and mechanical restraint reduction interventions were varied, with several interventions resulting in both reduced and unchanged or increased use. Outcomes were also reported for combinations of several interventions in the form of reduction programmes for both seclusion and mechanical restraint. Much of the research focused on implementing several interventions simultaneously, making it difficult to distinguish outcomes. Further research is suggested on the effectiveness of interventions and the contexts they are implemented in.

Relationship Between Adverse Childhood Experience Survey Items and Psychiatric Disorders

CONTEXT

Developmental psychopathology theory suggests a relationship between early childhood adversity and mental disorder.

OBJECTIVE

To examine the relationship between the specific items on the Adverse Childhood Experiences (ACE) survey and the International Classification of Diseases, Tenth Revision (ICD-10) categories of psychiatric diagnoses in a pediatric sample.

DESIGN

The sample included patients enrolled in the Child and Adolescent Addiction Mental Health and Psychiatry Program with both a completed ACE survey and at least 1 diagnosis of record (per admission). These criteria yielded 2 samples for each sex (ACE survey item frequencies and values in collapsed and multiple-admission groups). Data were analyzed employing tetrachoric correlation, hierarchical regression, and polychoric factor analysis.

RESULTS

Hierarchical regression analysis identified that ICD-10 diagnostic categories, except for substance disorders, were not consistently related to ACE total score and tended to reduce the magnitude of the ACE total score in the multiple-admission group. Tetrachoric correlation revealed very low (< 0.4) positive and negative correlations between ICD-10 categories and ACE items in both multiple-admission and collapsed sample groups. Polychoric factor analysis indicated that the ACE survey items and the ICD-10 categories for both sexes were independent, with only the diagnostic ICD-10 category substance disorders being marginally associated with the ACE items factor for females.

CONCLUSION

The nominal relationship between ACE items and ICD-10 diagnostic categories indicates the need to include ACE assessment in advance of differential diagnosis and implementation of conventional mental health interventions for children and adolescents.

Autism and Accommodations in Higher Education: Insights from the Autism Community

This article builds on the growing body of research on higher education for autistic students by soliciting input from autistic adults on their higher education experiences and suggestions on making these experiences more 'autism-friendly'. Sixty-six individuals participated in a national exploratory survey and thirty-one participated in follow-up, online focus groups. The article reviews the accommodations individuals received and the accommodations they would have liked to receive. Concrete strategies are provided for institutes of higher education to address the social and sensory needs of autistic students, areas many participants reported being neglected in their academic experience, such as mentors and a neurodiverse space. These suggestions are intended to complement traditional academic accommodations to improve the outcomes of autistic students.

It's like another world: the perceived beneficial effects of an artistically designed multisensory environment

Self-management strategies have been identified as having a key role in supporting mental health and preventing mental illness. Evidence suggests that spending time in nature, experiencing or viewing artwork and accessing sensory rooms all support self-management and positive mental health among varied clinical populations. This evidence informed the design of the sensory-art space (SAS), an artistically designed multisensory environment, which drew on themes and images of nature.The aim of this study was to explore the experiences and perceived benefits of the SAS among members of a university community.A maximum variation approach to sampling was used, and 18 participants were included in this qualitative study. Data were gathered via semi-structured interviews, which were audio-recorded and transcribed verbatim for thematic analysis.The findings presented six themes. The two core themes were: it's like another world, and easy to focus and describe how the SAS produced the beneficial effects described in the four remaining themes of: emotionally nutritious, meditative effects, relaxation and therapeuticParticipants identified beneficial effects of the SAS that were consistent with the evidence for other self-management strategies. The identified benefits also aligned with existing theories suggesting that the SAS functioned as a restorative environment. This study is the first to explore the experience of art in a multisensory and multidimensional capacity, which further contributes to the growing field of receptive engagement with the arts for health outcomes.

Does a new spatial design in psychiatric inpatient care influence patients' and staff's perception of their care/working environment? A study protocol of a pilot study using a single-system experimental design

Background

Research shows that worn-out physical environments are obstacles to psychiatric inpatient care. Patients want better relationships with staff and things to do; staff want an environment that offers hope, a calm atmosphere, and joint activities. A county council in northern Sweden and Philips Healthcare partnered to create solutions to the environmental challenges of psychiatric inpatient care. One ward at a county psychiatric clinic was selected for a pilot project to test solutions that could improve the care environment for patients, staff, and relatives. The aim of the overall project is to evaluate the effects of a newly designed psychiatric inpatient ward on patients and staff in terms of quality of care and stress. In this study, we focus on the feasibility through testing questionnaires and exploring barriers to recruiting staff and patients.

Methods

This study had a single-system experimental design, comparing a psychiatric unit pre- and post-implementation of the novel spatial design, using repeated measures with the same questionnaires twice a week during baseline and intervention phases. Primary outcomes were quality interactions (patients) and perceived stress (staff). Secondary outcomes were levels of anxiety and depression (patients), and stress of conscience (staff). A process evaluation was aimed to describe contextual factors and participant experiences of the new design. Data was collected using questionnaires and semi-structured individual interviews with patients and focus group discussions with staff. Both visual and statistical methods were used to analyse the quantitative data and content analysis for the qualitative data.

Discussion

The findings will contribute insights into whether and how a new spatial design might contribute to quality interactions and reduced stress. This is relevant both nationally and internationally, as similar interventions are needed but sparse. The findings will be disseminated through peer-reviewed publications and conference presentations.

Trial registration

ClinicalTrials.gov, NCT03140618, registered 4 May 2017

Sensory strategies in adult mental health: A qualitative exploration of staff perspectives following the introduction of a sensory room on a male adult acute ward

In recent years, there has been growing interest in the use of sensory techniques to help with emotional regulation in adult mental health populations. This is against a backdrop of international policies aimed at reducing restrictive interventions and improving the effectiveness of de-escalation techniques. A sensory room was designed and implemented on a male adult acute psychiatric ward. Staff perspectives were sought to evaluate the effectiveness of the room in managing emotional distress by exploring staff awareness of a broader range of de-escalation strategies and by exploring what effect the room had on staff behaviours with respect to sensory interventions. A series of semi-structured interviews were carried out, analysed, and grouped into themes. Three themes emerged as follows: enhancing de-escalation, sensory interventions, and impact on staff. Findings showed that increased awareness of sensory processing and use of sensory strategies such as the sensory room were perceived by staff to have a positive impact on reducing distress with male service users. Staff use of the room was also discovered to have benefits that included staff attending to their own emotional needs and the use of the room supporting reflective learning during critical incident debriefing.

Staff and patient accounts of PRN medication administration and non-pharmacological interventions for anxiety

Most psychiatric inpatients will receive psychotropic PRN medication during their hospital stay for agitation, anxiety, and/or insomnia. While helpful in some cases, caution is warranted with regard to PRN use due to inherent risks of additional medication; therefore, experts advise that non-pharmacological interventions should be attempted first where indicated. However, research to date highlights that, in practice, non-pharmaceutical approaches are attempted in a minority of cases. While some information is known about the practice of PRN administration and the use of and barriers to implementing non-pharmacological interventions for treating acute psychiatric symptoms, full understanding of this practice is hampered by poor or altogether missing documentation of the process. This study used interviews with patients and staff from two psychiatric hospitals to collect first-person accounts of administering PRN medication for anxiety, thereby addressing the limitations of relying on documented notation found in previous research. Our results indicate that nurses are engaging in non-pharmacological interventions more often than had previously been captured in research. However, the types of strategies suggested are not typically evidence based and further, only happening approximately half the time. The barriers to providing such care are centred on two main beliefs about client choice and efficacy of these non-medical strategies. Implications for research and practice are discussed.

The benefits of sensory modulation on levels of distress for consumers in a mental health emergency setting

OBJECTIVES

This paper reports a pilot study exploring the benefits of offering sensory modulation within a mental health emergency setting for consumers experiencing distress during a psychiatric presentation.

METHODS

Seventy-four consumers with a mental health presentation reported on their sensory modulation use experiences during their stay in a South Australian tertiary teaching hospital emergency department. An evaluation form was used to document use of items, self-reported distress pre and post sensory modulation use, and other consumer experiences.

RESULTS

Consumers used between one and six sensory items for a median duration of 45 min. There was a statistically significant reduction ( t(73) = 15.83, p < .001) in self-reported distress post sensory modulation use, and consumers also reported that use was helpful, distracting, calming and assisted in managing negative emotions and thoughts.

CONCLUSIONS

The results demonstrate the potential value of sensory-based interventions in reducing behavioural and emotional dysregulation in an emergency setting whilst also promoting consumer self-management strategies.

Preparing mental health professionals for new directions in mental health practice: Evaluating the sensory approaches e-learning training package

The application of sensory modulation approaches in mental health settings is growing in recognition internationally. However, a number of barriers have been identified as limiting the implementation of the approach, including workplace culture and a lack of accessible and effective sensory approaches training. The aim of this project was to investigate the efficacy of providing this training through a custom-designed e-learning package. Participants in the present study were predominately nurses and occupational therapists working in mental health settings in Queensland, Australia. Data were collected from 121 participants using an online survey. Significant improvements were found between pre- and post-training in participants' real and perceived levels of knowledge, their perceived levels of confidence, and their attitudes towards using sensory modulation approaches in mental health settings. The findings of the study suggest that the custom-designed sensory approaches e-learning package is an effective, accessible, acceptable, and usable method to train health professionals in sensory modulation approaches. As this study is the first to analyse the efficacy of an e-learning sensory approaches package, the results are considered preliminary, and further investigation is required.

Sensory Reduction on the General Milieu of a High-Acuity Inpatient Psychiatric Unit to Prevent Use of Physical Restraints: A Successful Open Quality Improvement Trial

BACKGROUND

Impaired sensory gating in patients with acute mental illness predisposes to overstimulation and behavioral dyscontrol.

OBJECTIVE

Explore use of sensory reduction interventions on a high-acuity inpatient milieu to reduce high assault/restraint rates.

DESIGN

A multidisciplinary team using failure mode and effect analysis to explore high restraint use between 4:00 p.m. and 7:00 p.m. observed patient/staff overstimulation contributed to behavioral escalations. The team implemented sensory reduction/integration improvements over a 5-month period to prevent excessive restraint use.

RESULTS

Restraint rates dropped immediately following light and sound reduction interventions and by 72% at 11 months postimplementation. Mann-Whitney statistics for unpaired 6-month comparisons, 1-year pre- and postintervention showed significant reductions: Assault rates (median pre = 1.37, post = 0.18, U = 4, p = .02); Restraint rates (median pre = 0.50, post = 0.06, U = 0, p = .002).

CONCLUSION

Sensory reduction during a high-stress time period on a high-acuity psychiatric unit was associated with a reduction in assaults and restraints.

De-escalation techniques used, and reasons for seclusion and restraint, in a forensic psychiatric hospital

In Finland, the Mental Health Act determines the legal basis for seclusion and restraint. Restrictive measures are implemented to manage challenging situations and should be used as a last resort in psychiatric inpatient care. In the present study, we examined the reasons for seclusion and restraint, as well as whether any de-escalation techniques were used to help patients calm down. Seclusion and restraint files from a 4-year period (1 June 2009-31 May 2013) were retrospectively investigated and analysed by content analysis. Descriptive statistics were calculated. A total of 144 episodes of seclusion and restraint were included to analyse the reasons for seclusion and restraint, and 113 episodes were analysed to examine unsuccessful de-escalation techniques. The most commonly-used techniques were one-to-one interaction with a patient (n = 74, 65.5% of n = 113) and administration of extra medication (n = 37, 32.7% of n = 113). The reasons for seclusion and restraint were threatening harmful behaviour (n = 51, 35.4% of n = 144), direct harmful behaviour (n = 43, 29.9%), indirect harmful behaviour (n = 42, 29.1%), and other behaviours (n = 8, 5.6%). In general, the same de-escalation techniques were used with most patients. Most episodes of seclusion or restraint were due to threats of violence or direct violence. Individual means of self-regulation and patient guidance on these techniques are needed. Additionally, staff should be educated on a diverse range of de-escalation techniques. Future studies should focus on examining de-escalation techniques for the prevention of seclusion.

Sensory rooms in psychiatric inpatient care: Staff experiences

There is an increased interest in exploring the use of sensory rooms in psychiatric inpatient care. Sensory rooms can provide stimulation via sight, smell, hearing, touch and taste in a demand-free environment that is controlled by the patient. The rooms may reduce patients' distress and agitation, as well as rates of seclusion and restraint. Successful implementation of sensory rooms is influenced by the attitudes and approach of staff. This paper presents a study of the experiences of 126 staff members who worked with sensory rooms in a Swedish inpatient psychiatry setting. A cross-sectional descriptive survey design was used. Data were collected by a web based self-report 12-item questionnaire that included both open- and closed-ended questions. Our findings strengthen the results of previous research in this area in many ways. Content analyses revealed three main categories: hopes and concerns, focusing on patients' self-care, and the room as a sanctuary. Although staff initially described both negative and positive expectations of sensory rooms, after working with the rooms, there was a strong emphasis on more positive experiences, such as letting go of control and observing an increase in patients' self-confidence, emotional self-care and well-being. Our findings support the important principals of person-centred nursing and recovery-oriented mental health and the ability of staff to implement these principles by working with sensory rooms.

Educating Mental Health Clinicians About Sensory Modulation to Enhance Clinical Practice in a Youth Acute Inpatient Mental Health Unit: A Feasibility Study

There is an emergence of literature describing effective sensory modulation (SM) interventions to de-escalate violence and aggression among mental health inpatients. However, the evidence is limited to adult settings, with the effect of SM in youth acute settings unknown. Yet, before SM may be used as a de-escalation intervention in youth acute settings, multidisciplinary staff need to be educated about and supported in the clinical application of SM. In the current study, an online SM education package was developed to assist mental health staff understand SM. This was blended with action learning sets (ALS), small group experiential opportunities consisting staff and consumers to learn about SM resources, and the support of SM trained nurses. The aims of the study were to evaluate the effectiveness of this SM education intervention in (a) transferring knowledge of SM to staff, and (b) translating this knowledge into practice in a youth acute inpatient mental health unit. A mixed methods research design with an 11-item pre- and post-education questionnaire was used along with three-month follow-up focus groups. The SM education improved understanding about SM (all 11-items p ≤ 0.004, r ≥ 0.47). Three-months after SM education, four themes evident in the focus group data emerged about the practice and process of SM; (1) translating of learning into practice, (2) SM in practice, (3) perceptions of SM benefits, and (4) limitations of SM. A blended SM education process enhanced clinical practice in the unit, yet participants were mindful of limitations of SM in situations of distress or escalating agitation.

Research priorities in mental health occupational therapy: A study of clinician perspectives

BACKGROUND/AIM

The evidence to support mental health occupational therapy has proliferated in the early years of this century, but this growth has tended to be organic rather than targeted. Previous efforts to identify research priorities in this area of practice are either out dated, or encompass discrete areas of practice. The aim of this study was to identify priority areas for research in mental health occupational therapy from clinician's perspectives.

METHODS

A Policy Delphi method was used to enable occupational therapists to define and differentiate their perspectives on research priorities. Forty-two occupational therapists took part in the first two rounds of this method, with 69% (n = 29) going on to complete the third and final round of data collection. A Likert scale was used to rate the importance of each priority, and descriptive quantitative analysis undertaken to identify those most consistently identified as being highly important.

RESULTS

Four research priorities were identified as being highly important in this study: (i) working in an occupationally focussed way; (ii) consumer experience of therapy groups; (iii) identifying factors which increase consumer engagement in occupation; and (iv) engaging patients on the inpatient unit in meaningful and positive occupation.

CONCLUSIONS

Two of the priority areas are already the subject of substantial evidence bases, but there has been far less research into consumer experiences of groups and occupational engagement in acute settings. Collaboration between research teams and greater consumer inclusion are recommended for the future.

SIGNIFICANCE OF THE STUDY

This study provides an updated indication of research priorities for mental health occupational therapy in Australia.

Understanding Mental Health Service User Experiences of Restraint Through Debriefing: A Qualitative Analysis

OBJECTIVE

To examine debriefing data to understand experiences before, during, and after a restraint (seclusion, chemical, and physical) event from the perspective of inpatients at a large urban mental health and addiction hospital.

METHOD

Audits were conducted on a purposeful sample of inpatient charts containing post-restraint event inpatient debrief forms (n = 55). Qualitative data from the forms were analyzed thematically.

RESULTS

Loss of autonomy and related anger, conflict with staff and other inpatients, and unmet needs were the most common factors precipitating restraint events. Inpatients often reported that increased communication with staff could have prevented restraint. Inpatients described having had various negative emotional states and responses during restraint events, including fear and rejection. Post-restraint, inpatients often desired to leave the unit for fresh air or to engage in leisure activities.

CONCLUSIONS

To our knowledge, our study is the first to use debriefing form data to explore mental health inpatients' experiences of restraint. Inpatients view restraint negatively and do not experience it as a therapeutic intervention. Debriefing, guided by a form, is useful for understanding the inpatient's experience of restraint, and should be used to re-establish the therapeutic relationship and to inform plans of care. In addition, individual and collective inpatient perspectives should inform alternatives to restraint.

Identifying educational priorities for occupational therapy students to prepare for mental health practice in Australia and New Zealand: Opinions of practising occupational therapists

BACKGROUND

The effective preparation of occupational therapy students for mental health practice is critical to facilitate positive consumer outcomes, underpin optimal practice and support new graduates' professional identity. This project was established to determine a set of 'educational priorities' for occupational therapy students to prepare them for current (and future) entry-level practice in mental health, from the perspective of mental health occupational therapists in Australia and New Zealand.

METHODS

The study included two phases. In Phase One, participants identified what they considered to be important educational priorities for occupational therapy students to prepare them for practice in mental health. For Phase Two, an 'expert panel' was assembled to review and rank these using a Policy Delphi approach.

RESULTS

Eighty-five participants provided educational priorities in Phase One. These were grouped into a total of 149 educational themes. In Phase Two, the expert panel (consisting of 37 occupational therapists from diverse locations and practice settings) prioritised these themes across three Delphi rounds. A final priority list was generated dividing educational themes into three prioritised categories: 29 'Essential', 25 'Important' and 44 'Optional' priorities. Highest-ranked priorities were: clinical reasoning, client-centred practice, therapeutic use of self, functional implications of mental illness, therapeutic use of occupation and mental health fieldwork experience.

CONCLUSION

The priority list developed as part of this project provides additional information to support the review of occupational therapy curricula across Australia and New Zealand to ensure that new graduates are optimally prepared for mental health practice.