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Rogers JP, Lewis G, Lobo M, Wyke C, Meaburn A, Harding F, Garvey R, Irvine J, Yahya AS, Kornblum D, Cullen AE, Mirfin D, Lewis G. Identifying predictors of adverse outcomes after termination of seclusion in psychiatric intensive care units. BJPsych Open 2024; 10:e120. [PMID: 38773812 DOI: 10.1192/bjo.2024.710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND Seclusion is a restrictive practice that many healthcare services are trying to reduce. Previous studies have sought to identify predictors of seclusion initiation, but few have investigated factors associated with adverse outcomes after seclusion termination. AIMS To assess the factors that predict an adverse outcome within 24 h of seclusion termination. METHOD In a cohort study of individuals secluded in psychiatric intensive care units, we investigated factors associated with any of the following outcomes: actual violence, attempted violence, or reinitiation of seclusion within 24 h of seclusion termination. Among the seclusion episodes that were initiated between 29 March 2018 and 4 March 2019, we investigated the exposures of medication cooperation, seclusion duration, termination out of working hours, involvement of medical staff in the final seclusion review, lack of insight, and agitation or irritability. In a mixed-effects logistic regression model, associations between each exposure and the outcome were calculated. Odds ratios were calculated unadjusted and adjusted for demographic and clinical variables. RESULTS We identified 254 seclusion episodes from 122 individuals (40 female, 82 male), of which 106 (41.7%) had an adverse outcome within 24 h of seclusion termination. Agitation or irritability was associated with an adverse outcome, odds ratio 1.92 (95% CI 1.03 to 3.56, P = 0.04), but there was no statistically significant association with any of the other exposures, although confidence intervals were broad. CONCLUSIONS Agitation or irritability in the hours preceding termination of seclusion may predict an adverse outcome. The study was not powered to detect other potentially clinically significant factors.
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Affiliation(s)
| | | | - Maria Lobo
- South London and Maudsley NHS Foundation Trust, London, UK
| | | | | | - Fiona Harding
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Rebecca Garvey
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Jenny Irvine
- South London and Maudsley NHS Foundation Trust, London, UK
| | | | - Daisy Kornblum
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Alexis E Cullen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - David Mirfin
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, UK
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Baggio S, Kaiser S, Wullschleger A. Effect of Seclusion on Mental Health Status in Hospitalized Psychiatric Populations: A Trial Emulation using Observational Data. Eval Health Prof 2024; 47:3-10. [PMID: 36898680 PMCID: PMC10858627 DOI: 10.1177/01632787231164489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
The use of coercive practices, i.e., interventions against a person's will, is controversial. Recent observational studies highlighted their potential detrimental effects on patients' mental health, but this topic remains understudied. This study investigated the effect of a common coercive practice, seclusion (i.e., being locked in a closed room), on mental health using a trial emulation of observational data to allow causal inference. We used data from 1200 psychiatric inpatients, classified as being either secluded or non-secluded during their hospital stay. Inverse probability of treatment weighting was used to emulate the random assignment to the intervention. The primary outcome was the Health of the Nations Outcome Scales (HoNOS). The secondary outcome was the first item of the HoNOS, which focuses on overactive, aggressive, disruptive, or agitated behavior. Both outcomes were assessed at hospital discharge. There was a significant effect of seclusion with increases in both total HoNOS score (p = .002) and item 1 of the HoNOS (p = .01). Seclusion may have a negative causal effect of patients' mental health status and should therefore be avoided in mental health care settings. Training efforts should raise the awareness of the medical staff about potential adverse effects instead of therapeutic benefits.
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Affiliation(s)
- Stéphanie Baggio
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Division of Prison Health, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Stefan Kaiser
- Adult Psychiatry Division, Department of Psychiatry, Geneva University Hospitals, Geneva, Switzerland
| | - Alexandre Wullschleger
- Adult Psychiatry Division, Department of Psychiatry, Geneva University Hospitals, Geneva, Switzerland
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Varpula J, Välimäki M, Pulkkinen J, Lantta T. Patient Falls in Seclusion Rooms in Psychiatric Inpatient Care: A Sociotechnical Probabilistic Risk Modeling Study. J Nurs Care Qual 2023; 38:190-197. [PMID: 36476941 PMCID: PMC9944373 DOI: 10.1097/ncq.0000000000000683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patient falls are a major adverse event in psychiatric inpatient care. PURPOSE To model the risk for patient falls in seclusion rooms in psychiatric inpatient care. METHODS Sociotechnical probabilistic risk assessment (ST-PRA) was used to model the risk for falls. Data sources were the research team, literature review, and exploration groups of psychiatric nurses. Data were analyzed with fault tree analysis. RESULTS The risk for a patient fall in a seclusion room was 1.8%. Critical paths included diagnosis of a psychiatric disorder, the mechanism of falls, failure to assess and prevent falls, and psychological or physical reason. The most significant individual risk factor for falls was diagnosis of schizophrenia. CONCLUSIONS Falls that occur in seclusion events are associated with physical and psychological risk factors. Therefore, risk assessment methods and fall prevention interventions considering patient behavioral disturbance and physiological risk factors in seclusion are warranted.
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Affiliation(s)
- Jaakko Varpula
- Department of Nursing Science, University of Turku, Turku, Finland (Mr Varpula and Drs Välimäki and Lantta); Xiangya Center for Evidence-Based Practice and Healthcare Innovation, Central South University, Hunan, China (Dr Välimäki); Hospital District of Southwest Finland, Turku, Finland (Dr Pulkkinen); and Department of Nursing, Faculty of Health and Education, Manchester Metropolitan University, Manchester, United Kingdom (Dr Lantta)
| | - Maritta Välimäki
- Department of Nursing Science, University of Turku, Turku, Finland (Mr Varpula and Drs Välimäki and Lantta); Xiangya Center for Evidence-Based Practice and Healthcare Innovation, Central South University, Hunan, China (Dr Välimäki); Hospital District of Southwest Finland, Turku, Finland (Dr Pulkkinen); and Department of Nursing, Faculty of Health and Education, Manchester Metropolitan University, Manchester, United Kingdom (Dr Lantta)
| | - Johanna Pulkkinen
- Department of Nursing Science, University of Turku, Turku, Finland (Mr Varpula and Drs Välimäki and Lantta); Xiangya Center for Evidence-Based Practice and Healthcare Innovation, Central South University, Hunan, China (Dr Välimäki); Hospital District of Southwest Finland, Turku, Finland (Dr Pulkkinen); and Department of Nursing, Faculty of Health and Education, Manchester Metropolitan University, Manchester, United Kingdom (Dr Lantta)
| | - Tella Lantta
- Department of Nursing Science, University of Turku, Turku, Finland (Mr Varpula and Drs Välimäki and Lantta); Xiangya Center for Evidence-Based Practice and Healthcare Innovation, Central South University, Hunan, China (Dr Välimäki); Hospital District of Southwest Finland, Turku, Finland (Dr Pulkkinen); and Department of Nursing, Faculty of Health and Education, Manchester Metropolitan University, Manchester, United Kingdom (Dr Lantta)
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Abstract
The appropriate treatment of mentally unwell, aggressive patients has challenged psychiatry for centuries. Seclusion is practiced worldwide, but concerns remain regarding its appropriateness and lack of alternatives. Patients generally report seclusion as a negative experience, though there is a paucity of literature exploring this in detail. This investigation was a service evaluation appraising inpatients' perspective of processes occurring before (information, communication), during (review, care), and after (debrief, reflection) seclusion in a psychiatric intensive care unit (PICU). In this phenomenological study, qualitative data were gathered using a questionnaire in a structured interview. All patients had been nursed in seclusion during admission to a male PICU at South London and the Maudsley NHS Foundation Trust. Ten patients were interviewed over 4 months. The central theme was perceived lack of communication in the patient-professional relationship, which manifested itself as (i) violence against patients, (ii) lack of psychological support, and (iii) the need for alternatives. Such feedback from patients queries whether national guidelines are appropriate and/or being adhered to. Healthcare practitioners have a responsibility to challenge accepted practice to continually improve the standard of patient-centred care. Utilising patient perspectives can be a powerful driver of change towards more humane treatment of vulnerable patients.
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Affiliation(s)
- Silvia Allikmets
- Department of Life Sciences & Medicine, GKT School of Medical Education, King's College London, London, United Kingdom
| | - Caryl Marshall
- Southwark High Support Rehabilitation, South London and the Maudsley NHS Foundation Trust, London, United Kingdom.,Community Forensic LD/ASD, Oxleas NHS Foundation Trust, South London Partnership, London, United Kingdom
| | - Omar Murad
- Psychiatric Intensive Care, South London and the Maudsley NHS Foundation Trust, London, United Kingdom
| | - Kamal Gupta
- South London and the Maudsley NHS Foundation Trust, London, United Kingdom
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Newton-Howes G. Do Community Treatment Orders in Psychiatry Stand Up to Principalism: Considerations Reflected through the Prism of the Convention on the Rights of Persons with Disabilities. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2019; 47:126-133. [PMID: 30994070 DOI: 10.1177/1073110519840492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Compulsory psychiatric treatment is the norm in many Western countries, despite the increasingly individualistic and autonomous approach to medical interventions. Community Treatment Orders (CTOs) are the singular best example of this, requiring community patients to accept a variety of interventions, both pharmacological and social, despite their explicit wish not to do so. The epidemiological, medical/treatment and legal intricacies of CTOs have been examined in detail, however the ethical considerations are less commonly considered. Principlism, the normative ethical code based on the principles of autonomy, beneficence, non-maleficence and justice, underpins modern medical ethics. Conflict exists between patient centred commentary that reflects individual autonomy in decision making and the need for supported decision making, as described in the Convention on the Rights of Persons with Disabilities (CRPD) and the increasing use of such coercive measures, which undermines this principle. What appears to have been lost is the analysis of whether CTOs, or any coercive measure in psychiatric practice measures up against these ethical principles. We consider whether CTOs, as an exemplar of coercive psychiatric practice, measures up against the tenets of principalism in the modern context in order to further this debate.
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Affiliation(s)
- Giles Newton-Howes
- Giles Newton-Howes, B.A., B.Sc., M.B.Ch.B., M.R.C.Psych., F.R.A.N.Z.C.P., PostDip.C.B.T., Ph.D., is an associate professor in the department of psychological medicine, University of Otago, Wellington. He is seconded to Te-Upoko-me-Te-Karuo-Te-Ika, the public health service that delivers mental health care to the lower part of the North Island of New Zealand, where he works as a consultant psychiatrist
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Green R, Shelly C, Gibb J, Walker T. Implementing seclusion in forensic mental health care: A qualitative study of staff decision making. Arch Psychiatr Nurs 2018; 32:764-768. [PMID: 30201206 DOI: 10.1016/j.apnu.2018.04.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 03/27/2018] [Accepted: 04/18/2018] [Indexed: 10/17/2022]
Abstract
Forensic mental health nursing is a complex role and there is a tension between maintaining safety and promoting a therapeutic and patient centred approach. The use of restrictive practises such as seclusion is an issue. Two focus groups with registered nurses exploring attitudes and factors used in decision-making about seclusion use were analysed using interpretive description. Participants described the need to reduce the use of seclusion and the problematic nature of its utility as an ongoing intervention in contemporary mental healthcare. It was clear that there were complexities and competing variables involved in the decision-making process.
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Affiliation(s)
- Rachel Green
- Greater Manchester Mental Health NHS Foundation Trust, Prestwich Hospital, Bury New Rd, Manchester, M25 3BL, United Kingdom.
| | - Catriona Shelly
- Manchester Metropolitan University, Department of Psychology, 53 Bonsall Street, Manchester M15 6GX, United Kingdom.
| | - Jonathan Gibb
- University of Manchester, Division of Psychology and Mental Health, School of Medical Sciences, Oxford Road, Manchester M13 9PL, United Kingdom.
| | - Tammi Walker
- The University of Huddersfield, Human and Health Sciences, Queensgate, Huddersfield HD1 3DH, United Kingdom.
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