Methodological and ethical challenges in studying patients' perceptions of coercion: a systematic mixed studies review

"It was not normal, and I had to find a doctor and tell him." Kenyan Women's Response to Cervical Cancer Symptoms

This study aimed to characterize the cervical cancer diagnosis experience of Kenyan women undergoing treatment for cervical cancer. We analyzed qualitative interviews with 29 women living in rural Kenya who were currently undergoing cervical cancer treatment at Machakos Cancer Care and Research Centre at Machakos Level 5 Referral Hospital in eastern Kenya. Semistructured qualitative interviews were conducted in Kiswahili and English and then de-identified and translated to English during transcription. The main themes generated were identified through an inductive approach to determine how women experienced cervical cancer symptoms and their process of navigating healthcare. Three themes emerged from the qualitative interviews: (1) delaying seeking care, (2) misinterpreting or misdiagnoses, and (3) grappling with the costly diagnosis process. Women misattributed early signs of cervical cancer to benign conditions. Women sought care only after experiencing severe symptoms. When they sought care, women reported facing lengthy and costly screening processes before receiving a cervical cancer diagnosis. There is a need to educate women on the early symptoms of cervical cancer and to increase the institutional capacity and availability of cervical cancer screening resources in healthcare facilities.

Qualitative study of patient experiences and care observations during agitation events in the emergency department: implications for systems-based practice

OBJECTIVES

Agitation, defined as excessive psychomotor activity leading to aggressive or violent behaviour, is prevalent in the emergency department (ED) due to rising behavioural-related visits. Experts recommend use of verbal de-escalation and avoidance of physical restraint to manage agitation. However, bedside applications of these recommendations may be limited by system challenges in emergency care. This qualitative study aims to use a systems-based approach, which considers the larger context and system of healthcare delivery, to identify sociotechnical, structural, and process-related factors leading to agitation events and physical restraint use in the ED.

DESIGN

Qualitative study using a grounded theory approach to triangulate interviews of patients who have been physically restrained with direct observations of agitation events.

SETTING

Two EDs in the Northeast USA, one at a tertiary care academic centre and the other at a community-based teaching hospital.

PARTICIPANTS

We recruited 25 individuals who experienced physical restraint during an ED visit. In addition, we performed 95 observations of clinical encounters of agitation events on unique patients. Patients represented both behavioural (psychiatric, alcohol/drug use) and non-behavioural (medical, trauma) chief complaints.

RESULTS

Three primary themes with implications for systems-based practice of agitation events in the ED emerged: (1) pathways within health and social systems; (2) interpersonal contexts as reflections of systemic stressors on behavioural emergency care and (3) systems-based and patient-oriented strategies and solutions.

CONCLUSIONS

Agitation events represented manifestations of patients' structural barriers to care from socioeconomic inequities and high burden of emotional and physical trauma as well as staff members' simultaneous exposure to external stressors from social and healthcare systems. Potential long-term solutions may include care approaches that recognise agitated patients' exposure to psychological trauma, improved coordination within the mental health emergency care network, and optimisation of physical environment conditions and organisational culture.

Physical Restraint in Psychiatric Care: Soon to Fall Out of Use?

International directives all recommend that using restraints on psychiatric patients should be avoided, yet scientific literature shows that such practices are still largely in use. This article aims to lay out strategies that could be put in place in order to gradually discard the use of restraints, particularly through a "restraint-free" approach, nursing, logistic-environmental pathways, and locally centered health care provision. All such tools have proven valuable for the purpose of safeguarding the health of psychiatric patients. Hence, the failure to put in place such measures may lead to litigation and lawsuits against physicians and particularly health care facilities. Undoubtedly, the ability to effectively implement such methods largely depends on the financial resources available, which in countries such as Italy are poorer than in others. Still, the risk of being sued and held professionally liable may constitute a factor in raising awareness among operators, facilities, and public health care management, leading to the implementation of policy changes aimed at minimizing the use of restraints.

Experiences of Individuals Who Were Physically Restrained in the Emergency Department

IMPORTANCE

Individuals with behavioral disorders are increasingly presenting to the emergency department (ED), and associated episodes of agitation can cause significant safety threats to patients and the staff caring for them. Treatment includes the use of physical restraints, which may be associated with injuries and psychological trauma; to date, little is known regarding the perceptions of the use of physical restraint among individuals who experienced it in the ED.

OBJECTIVE

To characterize how individuals experience episodes of physical restraint during their ED visits.

DESIGN, SETTING, AND PARTICIPANTS

In this qualitative study, semistructured, 1-on-1, in-depth interviews were conducted with 25 adults (ie, aged 18 years or older) with a diverse range of chief concerns and socioeconomic backgrounds who had a physical restraint order associated with an ED visit. Eligible visits included those presenting to 2 EDs in an urban Northeast city between March 2016 and February 2018. Data analysis occurred between July 2017 and June 2018.

MAIN OUTCOMES AND MEASURES

Basic participant demographic information, self-reported responses to the MacArthur Perceived Coercion Scale, and experiences of physical restraint in the ED.

RESULTS

Data saturation was reached with 25 interviews (17 [68%] men; 18 [72%] white; 19 [76%] non-Hispanic). The time between the patient's last restraint and the interview ranged from less than 2 weeks to more than 6 months. Of those interviewed, 22 (88%) reported a combination of mental illness and/or substance use as contributing to their restraint experience. Most patients (20 [80%]) said that they felt coerced to present to the ED. Three primary themes were identified from interviews, as follows: (1) harmful experiences of restraint use and care provision, (2) diverse and complex personal contexts affecting visits to the ED, and (3) challenges in resolving their restraint experiences, leading to negative consequences on well-being.

CONCLUSIONS AND RELEVANCE

In this qualitative study, participants described a desire for compassion and therapeutic engagement, even after they experienced coercion and physical restraint during their visits that created lasting negative consequences. Future work may need to consider more patient-centered approaches that minimize harm.

Trends in the use of coercive measures in Finnish psychiatric hospitals: a register analysis of the past two decades

BACKGROUND

Coercive measures is a topic that has long been discussed in the field of psychiatry. Despite global reports of reductions in the use of restraint episodes due to new regulations, it is still questionable if practices have really changed over time. For this study, we examined the rates of coercive measures in the inpatient population of psychiatric care providers across Finland to identify changing trends as well as variations in such trends by region.

METHODS

In this nationwide registry analysis, we extracted patient data from the national database (The Finnish National Care Register for Health Care) over a 20-year period. We included adult patients admitted to psychiatric units (care providers) and focused on patients who had faced coercive measures (seclusion, limb restraints, forced injection and physical restraints) during their hospital stay. Multilevel logistical models (a polynomial model of quadratic form) were used to examine trends in prevalence of any coercive measures as well as the other four specified coercive measures over time, and to investigate variation in such trends among care providers and regions.

RESULTS

Between 1995 and 2014, the dataset contained 226,948 inpatients who had been admitted during the 20-year time frame (505,169 treatment periods). The overall prevalence of coercive treatment on inpatients was 9.8%, with a small decrease during 2011-2014. The overall prevalence of seclusion, limb restraints, forced injection and physical restraints on inpatients was 6.9, 3.8, 2.6 and 0.8%, respectively. Only the use of limb restraints showed a downward trend over time. Geographic and care provider variations in specific coercive measures used were also observed.

CONCLUSIONS

Despite the decreasing national level of coercive measures used in Finnish psychiatric hospitals, the overall reduction has been small during the last two decades. These results have implications on the future development of structured guidelines and interventions for preventing and more effectively managing challenging situations. Clinical guidelines and staff education related to the use of coercive measures should be critically assessed to ensure that the staff members working with vulnerable patient populations in psychiatric hospitals are ethically competent.

[Reclusion and physical restraint in psychiatry: Influencing factors and alternatives.]

Introduction and context: The use of reclusion and restraint is neither a recent practice nor a rare practice in psychiatric services. In France, the Controller General of Places of Deprivation of Liberty reported certain drifts in 2015. Since then, the public authorities have sought to frame this practice with the aim of limiting its use.

OBJECTIVE AND METHOD

The purpose of this study is to examine how, through a literature review, the topic of limitation of constraint measures and the definition of a future direction of research is discussed.

RESULTS

It appears that health professionals seek to identify the cultural, social, and environmental characteristics of patients undergoing these restraint measures. However, they also question their approaches, both ethically, environmentally, organizationally, or through caregiving.

CONCLUSION

Co-ordination within the multidisciplinary team is mentioned but little discussed in this literature review. The place given to the role of nursing seems to be questionable, in terms of its specific approach, its expertise, and its field of action, and must be the subject of a new study.

A pilot study of "post-seclusion and/or restraint review" intervention with patients and staff in a mental health setting

PURPOSE

To develop and evaluate a "post-seclusion and/or restraint review" (PSRR) intervention implemented in an acute psychiatric care unit.

DESIGN AND METHODS

Twelve staff members and three patients were enrolled in a participatory case study. To evaluate PSRR intervention, qualitative analysis was carried out. Seclusion and restraint use 6 months before and after the PSRR implementation was compared.

FINDINGS

Nurses reported that they were able to explore the patient's feelings during the PSRR intervention with patients, which led to restoration of the therapeutic relationship. PSRR with the treatment team was perceived as a learning opportunity, which allowed to improve the therapeutic intervention. Both the use of seclusion and the time spent in seclusion were significantly reduced 6 months after the implementation of PSRR intervention.

PRACTICE IMPLICATION

Our results suggest the efficacy of PSRR in overcoming the discomfort perceived by both staff and patient and, in the meantime, in reducing the need for coercive procedures. Systematic PSRR could permit to improve the quality of care and the safety of aggressiveness management.

Informal coercion as a neglected form of communication in psychiatric settings in Germany and Switzerland

AIMS

Informal coercion is a frequently used form of communication among mental health professionals to influence treatment outcomes. This study investigates the recognition, attitude, and application of different forms of informal coercion by mental health professionals.

METHODS

Mental health professionals of five psychiatric institutions in Germany and Switzerland (n = 424) took part in an online survey assessing the recognition of, attitudes towards, and application of different forms of informal coercion.

RESULTS

Mental health professionals did not recognize the extent of informal coercion adequately; especially stronger forms were underestimated. Recognition and application of informal coercion was predicted by attitudes towards coercion. Furthermore, there were differences between profession of participants regarding the recognition and application of informal coercion.

CONCLUSIONS

It is important to realize that the extent of applied informal coercion in therapeutic communication is often not recognized by practitioners, although it might interfere with a sound therapeutic relationship.

[Predictive factors of seclusion duration in patients hospitalized in psychiatry settings. A prospective multisite study in the DTRF Paris-Sud]

INTRODUCTION

In psychiatric inpatient settings seclusion is a last resort to ensure the safety of the patient, other patients, and staff from disturbed behaviors. Despite its major interest for patients, seclusion could negatively impact treatment adherence and patient/staff relationships. Indeed, some secluded patients report a feeling of guilt during the measure and do not consider seclusion to be a healthcare intervention. To be more beneficial and to reduce the feeling by patients of being forced, seclusions should be as short and rare as possible. In other words, measures to reduce seclusion are available and have been clearly identified. Such measures could be applied, in the first instance, in patients with longer duration. In this way, the aim of this study was to investigate predictive factors of a seclusion of long duration.

METHODS

Our study was based on the dataset of the EPIC study, an observational prospective French multicenter study of seclusion and restraint. The EPIC study occurred in seven French psychiatric hospitals in the southern region of Paris. Inclusions were realized for 73days and allowed a data collection of 302 seclusion measures. Of these measures 236 were effectively a seclusion in a standardized room. Because the median duration was 7days, we defined two groups of patients: duration<7days and duration ≥ 7 days. Our variable to be explicated was duration ≥ 7 days. Explicative variables available in EPIC study were age, sex, forced hospitalization, autoagressivity, heteroagressivity, use of sedative treatment (oral or intramuscular), history of seclusion and patient diagnoses. We used bivariate and multivariate analyses to explore the association between a seclusion duration ≥ 7 days and explicative variables. Diagnoses were classified as psychotic disorders, mood disorders and others diagnoses. To be included in multivariate logistic regressions, diagnoses were treated as dummy variables (mood disorder vs psychotic disorders; psychotic disorders vs others; mood disorders vs others). Statistical analyses were performed using SPSS software 20.0 and R 3.4.0.

RESULTS

Of the 236 measures of seclusion the mean age was 38.2 (±12.8), 196 (83%) patients were forcibly hospitalized prior to their seclusion, 147 (62%) had a diagnosis of psychotic disorder, 43 (18%) a diagnosis of mood disorder and 33 (14%) an "other diagnosis". Mean duration was 10.2 (1.5) days and median was 7.1 days. One hundred and thirty-five (47%) patients were in the group of duration ≥ 7 days. In bivariate analyses, variables associated with a duration ≥ 7 days were: being in forced hospitalization prior to the seclusion (P=0.04), administration of a sedative treatment (P=0.01) and against the group of others diagnoses the diagnosis of mood disorders (P<0.0005) and psychotic disorders (P=0.001). Multivariate analyses showed that, against the group of other diagnoses, the group of psychotic disorders [OR=3.3, CI 95% (1.3-8.4), P=0.01], the group of mood disorder [OR=2.7, CI 95% (1.4-4.9), P=0.002] and administration of sedative treatment [OR=8.1, CI 95% (2.0-32.5), P=0.003] were significantly associated with a duration ≥ 7 days. These results were independent from other confusion variables. Considering the hospitalization status, psychotic disorders was the only diagnosis which showed an association between duration ≥ 7 days and forced hospitalization [OR=2.9 CI 95% (1.1-7.8), P=0.03].

CONCLUSION

Our study highlighted two profiles of higher risk to remain ≥ 7days in seclusion. The first one is patients with a diagnosis of mood disorder who needed sedative treatment. The second one is patients with a diagnosis of psychotic disorder who needed sedative treatment and forced hospitalized before seclusion. Thus, these two profiles could be a good target to practice, in the first instance, measures to reduce seclusion duration in psychiatry settings.

Variables Associated With the Subjective Experience of Coercive Measures in Psychiatric Inpatients: A Systematic Review

OBJECTIVE

This systematic review presents evidence regarding factors that may influence the patient's subjective experience of an episode of mechanical restraint, seclusion, or forced administration of medication.

METHOD

Two authors searched CINAHL, PubMed, SCOPUS, Web of Science, and Psych-Info, considering published studies between 1 January 1992 and 1 February 2016. Based on the inclusion criteria and methodological quality, 34 studies were selected, reporting a total sample of 1,869 participants.

RESULTS

The results showed that the provision of information, contact and interaction with staff, and adequate communication with professionals are factors that influence the subjective experience of these measures. Humane treatment, respect, and staff support are also associated with a better experience, and debriefing is an important procedure/technique to reduce the emotional impact of these measures. Likewise, the quality of the working and physical environment and some individual and treatment variables were related to the experience of these measures. There are different results in relation to the most frequently associated experiences and, despite some data that indicate positive experiences, the evidence shows such experiences to be predominantly negative and frequently with adverse consequences. It seems that patients find forced medication and seclusion to be more tolerable than mechanical restraint and combined measures.

CONCLUSIONS

It appears that the role of the staff and the environmental conditions, which are potentially modifiable, affect the subjective experience of these measures. There was considerable heterogeneity among studies in terms of coercive measures experienced by participants and study designs.

A Case Study: Seclusion and Restraint in Psychiatric Care

A wide breadth of research has recognized that seclusion and restraint affects patients, staff, and organizations alike. Therefore, it is essential to understand the viewpoints of all stakeholders to improve practices. The study aimed to understand the context in which seclusion and restraint practices are employed based on the perceptions of staff and inpatients in a psychiatric ward. A case study was performed using a participatory approach. Methods included a 56-hr immersion in the practice setting and individual interviews with staff and patients ( n = 17). The main themes discussed were patient characteristics (etiology of the violence, difficult experience), staff characteristics (feelings of safety, rationalization of seclusion use), and environmental characteristics. Both explicit (e.g., hospital protocol) and implicit (e.g., ward rules) standards seem to influence seclusion and restraint management. Our results point toward the potential for developing post-seclusion and restraint review in which both patient and staff perspectives are taken into account.

A Co-operative Inquiry Into Generating, Describing, and Transforming Knowledge About De-escalation Practices in Mental Health Settings

De-escalation is concerned with managing violent behaviour without resorting to coercive measures. Co-operative Inquiry provided the conceptual basis for generating knowledge regarding de-escalation practices in acute mental health care settings. The research included service users and staff members as co-researchers and knowledge was generated in dynamic research cycles around an extended epistemology of knowing: experiential, presentational, propositional, and practical. Through this process, co-researchers became de-escalation learners, implementing de-escalation practices while transforming violence management. Neighbouring mental health communities' involvement strengthened the transformation process and assisted in validating the research results.

A qualitative study examining the presence and consequences of moral framings in patients' and mental health workers' experiences of community treatment orders

BACKGROUND

Mental health recovery involves acknowledging the importance of building the person's capacity for agency. This might be particularly important for patients on community treatment orders (CTOs - which involve enforced treatment for their mental illness), given limited international evidence for their effectiveness and underlying concerns about the use of coercion by workers and systems of care towards this population of people with mental illness.

METHODS

This study sought to understand how the meaning of CTOs is constructed and experienced, from the perspective of patients on CTOs and workers directly administering CTOs. Qualitative interviews were conducted with South Australian community mental health patients (n = 8) and mental health workers (n = 10) in 2013-14. During thematic analysis of data, assisted by NVIVO software, the researchers were struck by the language used by both groups of participants and so undertook an examination of the moral framings apparent within the data.

RESULTS

Moral framing was apparent in participants' constructions and evaluations of the CTO experience as positive, negative or justifiable. Most patient participants appeared to use moral framing to: try to understand why they were placed on a CTO; make sense of the experience of being on a CTO; and convey the lessons they have learnt. Worker participants appeared to use moral framing to justify the imposition of care. Empathy was part of this, as was patients' positive right to services and treatment, which they believed would only occur for these patients via a CTO. Workers positioned themselves as trying to put themselves in the patients' shoes as a way of acting virtuously towards them, softening the coercive stick approach. Four themes were identified: explicit moral framing; best interests of the patient; lessons learned by the patient; and, empathy.

CONCLUSIONS

Experiences of CTOs are multi-layered, and depend critically upon empathy and reflection on the relationship between what is done and how it is done. This includes explicit examination of the moral framing present in everyday interactions between mental health workers and their patients in order to overcome the paradox of the moral grey zone between caring and controlling. It suggests a need for workers to receive ongoing empathy training.