eLearning course may shorten the duration of mechanical restraint among psychiatric inpatients: a cluster-randomized trial

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.

A systematic review of interventions to reduce mechanical restraint in adult mental health inpatient settings

Mechanical restraint is a commonly used restrictive practice worldwide, although reducing its use is an international priority. Interventions to reduce mechanical restraint are needed if reducing mechanical restraint is to succeed. Therefore, this systematic review aimed to examine evaluated evidence-based interventions that seek to reduce the incidence of and/or time in mechanical restraint in adult mental health inpatient settings. The JBI framework was used to guide this systematic review. The search strategy included peer-reviewed primary research literature published between 1999 and 2023. Two authors independently conducted the systematic search, selection process and data extraction process. Forty-one studies were included in this review. Using content analysis, we grouped interventions into four categories: (I) calm-down methods, (II) staff resources, (III) legal and policy changes and (IV) changing staff culture. Interventions to reduce mechanical restraint in adult mental health inpatient settings have shown some promise. Evidence suggests that a range of interventions can reduce the incidence of and/or time in mechanical restraint. However, controlled trials were lacking and consensus was lacking across studies. Furthermore, specific findings varied widely, and reporting was inconsistent, hampering the development of interventions for this issue. Further research is needed to strengthen the evidence base for reducing mechanical restraint in mental health inpatient settings.

Factors associated with prolonged episodes of mechanical restraint in mental health hospitalization units in Andalusia

WHAT IS KNOWN ON THE SUBJECT?: Risk factors associated with prolonged episodes of mechanical restraint and other coercive measures are understudied. There have been no studies of this phenomenon in the context of the Andalusian public health system. Knowledge about factors associated with prolonged episodes is essential to increase the understanding of this phenomenon and develop strategies to reduce its occurrence. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: In Andalusia, prolonged restraint is still frequent and varies depending on the unit. It is associated with less time since admission, male gender, diagnosis, reason for restraint and the shift on which it was initiated. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Interventions at the level of the units could be necessary to prevent prolonged episodes of mechanical restraint. The results suggest the need for stricter control during the shifts on which restraint starts, especially in the first days after the patient's admission. Preventive risk assessment considering clinical and sociodemographic risk factors could help to reduce prolonged restraint. ABSTRACT: Introduction Factors associated with prolonged episodes of mechanical restraint and other coercive interventions are not clearly established and have been not studied in Andalusia (Spain). Aim To study factors associated with prolonged episodes of mechanical restraint. Method We analysed retrospectively episodes of mechanical restraint (N = 6267, prolonged episode >9.5 hours) in all public mental health hospitalization units (N = 20, 535 beds) that offer health coverage for the autonomous community of Andalusia. The data came from clinical records. A multivariable mixed logistic regression was used. Results In Andalusia, prolonged restraint is still frequent and varies depending on the unit. It is associated with less time since admission, male gender, diagnosis, reason for restraint and the shift on which it was initiated. Discussion The results provide evidence that prolonged episodes largely depend on the unit where they occur and that stricter control and regulation are necessary to prevent prolonged episodes. Implications for practice Interventions at the level of the unit are necessary. Stricter control in the shifts during which there is more risk of prolonged restraint may be necessary, especially in the first days following admission.

An Evidence-Based Educational Intervention for Reducing Coercive Measures in Psychiatric Hospitals: A Randomized Clinical Trial

IMPORTANCE

Investing in health care staffs' education can change the scope of action and improve care. The effectiveness of staff education remains inconclusive.

OBJECTIVE

To examine whether an evidence-based educational intervention for nurses decreases the use of seclusion rooms in psychiatric hospitals compared with usual practice.

DESIGN, SETTING, AND PARTICIPANTS

In this pragmatic, 2-arm parallel, stratified cluster randomized clinical trial, 28 wards in 15 psychiatric hospitals in Finland were screened for eligibility and randomly allocated (1:1). Nurses joined on either intervention (n = 13) or usual practice (n = 15) wards. The intervention was performed from May 1, 2016, to October 31, 2017. The follow-up data for January 1 to December 31, 2017, were collected from hospital registers in 2018. Data analysis was performed October 27, 2021.

INTERVENTIONS

Evidence-based education delivered during 18 months, including 8 months of active education, followed by a 10-month maintenance period.

MAIN OUTCOMES AND MEASURES

The primary outcome was the occurrence of patient seclusion (events per total number of patients).

RESULTS

Of 28 psychiatric hospital wards screened (437 beds and 648 nurses), 27 wards completed the study. A total of 8349 patients were receiving care in the study wards, with 53% male patients and a mean (SD) age of 40.6 (5.7) years. The overall number of seclusions was 1209 (14.5%) in 2015 and 1349 (16.5%) in 2017. In the intervention group, the occurrence rate of seclusion at the ward level decreased by 5.3% from 629 seclusions among 4163 patients (15.1%) to 585 seclusions among 4089 patients (14.3%) compared with a 34.7% increase from 580 seclusions among 4186 patients (13.9%) to 764 seclusions among 4092 patients (18.7%) in the usual practice group. The adjusted rate ratio was 0.86 (95% CI, 0.40-1.82) in 2015 and 0.66 (95% CI, 0.31-1.41) in 2017 (P = .003). However, the number of forced injections increased in the intervention group from 317 events among 4163 patients (7.6%) in 2015 to 486 events among 4089 patients (11.9%) in 2017 compared with an increase in the usual practice group from 414 events among 4186 patients (9.9%) in 2015 to 481 events among 4092 patients (11.8%) in 2017. Seven adverse events were reported.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, the educational intervention had a limited effect on the change of occurrence rate of patient seclusion, whereas the use of forced injections increased. More studies are needed to better understand the reasons for these findings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02724748.

A Systematic Review of the Effectiveness of Safewards: Has Enthusiasm Exceeded Evidence?

Safewards is intended to be an evidence-based approach to reduce levels of conflict and containment in mental health inpatient settings. A systematic review was carried out to examine whether Safewards is effective in reducing conflict and containment events; and improving ward climate. Searches for articles evaluating the implementation of Safewards was conducted using PsycINFO, PubMed, Web of Science, Cochrane Library and CINAHL. Thirteen studies were included for review after applying inclusion and exclusion criteria. The Quality Assessment Tool for Studies with Diverse Designs (QATSDD) was used to assess study quality and the majority of studies (N = 7) were rated as "moderate" quality. Whilst there is evidence to suggest that Safewards is effective for reducing conflict and containment in general mental health services, there is insufficient high-quality empirical evidence to support its effectiveness in settings beyond this. Further research using robust methodological designs with larger, more representative samples is required in order for the effectiveness of Safewards to be established across the range of contexts in which it is currently being applied.

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

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

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.

Effectiveness of CRSCE-Based De-escalation Training on Reducing Physical Restraint in Psychiatric Hospitals: A Cluster Randomized Controlled Trial

Background: The use of physical restraint (PR) causes clinical and ethical issues; great efforts are being made to reduce the use of PR in psychiatric hospitals globally. Aim: This study aimed to examine the effectiveness of CRSCE-based de-escalation training on reducing PR in psychiatric hospitals. Method: The proposed study adopted cluster randomized controlled trial design. Twelve wards of a psychiatric hospital were randomly allocated to experimental group (n = 6) and control group (n = 6). Wards of control group were assigned to routine training regarding PR; wards of experimental group underwent the same routine training while additionally received CRSCE-based de-escalation training. Before and after CRSCE-based de-escalation training, the frequency of and the duration of PR, and the numbers and level of unexpected events caused by PR, were recorded. Results: After CRSCE-based de-escalation training, the frequency (inpatients and patients admitted within 24 h) of and the duration of PR of experimental group, showed a descending trend and were significantly lower than those of control group (P < 0.01); compared to control group, the numbers of unexpected events (level II and level III) and injury caused by PR of experimental group had been markedly reduced (P < 0.05). Conclusions: CRSCE-based de-escalation training would be useful to reduce the use of PR and the unexpected event caused by PR in psychiatric hospitals. The modules of CRSCE-based de-escalation training can be adopted for future intervention minimizing clinical use of PR. Clinical Trial Registration: This study was registered at Chinese Clinical Trial Registry (Registration Number: ChiCTR1900022211).

Nurses' perceptions of risks for occupational hazards in patient seclusion and restraint practices in psychiatric inpatient care: A focus group study

Seclusion and restraint are regularly used to manage patient aggression events in psychiatric inpatient care, despite occupational safety concerns. There is currently a lack of information on how nurses perceive the use of patient seclusion and restraint as a risk for occupational safety. The aim of this study is to describe the risks for occupational hazards in patient seclusion and mechanical restraint practices as well as ideas for improvement identified by nurses. A qualitative descriptive design was adopted, using focus groups comprising nurses (N = 32) working in psychiatric inpatient care. The data were analysed using inductive content analysis, and the results were reported using the consolidated criteria for reporting qualitative studies (COREQ). Four themes of risk for occupational hazards were identified: patient-induced, staff-induced, organization-induced, and environment-induced risks. One significant finding was that nurses described that their actions can strongly contribute to occupational hazards during seclusion and mechanical restraint practices. The nurses gave various ideas for how occupational safety could be improved during seclusion and mechanical restraint events, ideas involving staff, the organization, and environmental enhancements.

Prevalence, predictors, and patterns of mechanical restraint use for inpatients with dual diagnosis

PURPOSE

This study examined the prevalence, predictors, and patterns of mechanical restraint in an inpatient dual diagnosis population.

DESIGN AND METHODS

Data were longitudinally collected from patients affected by severe mental illness and comorbid substance abuse that were hospitalized in three large wards from 2006 to 2012.

FINDINGS

In a sample of 1698 hospitalizations, the use of mechanical restraint ranged between 1% and 4% per year. The diagnosis of schizophrenia (odds ratio [OR], 2.64; 95% confidence interval [CI], 1.29-5.40), the use of stimulant substances (OR, 5.68; 95% CI, 2.78-11.59) and male sex (OR, 3.22; 95% CI, 1.12-9.27) were associated with an increased risk of being exposed to mechanical restraint.

PRACTICE IMPLICATIONS

Specialized interventions targeting people at risk of mechanical restraint may further reduce the incidence of restraint and improve treatment outcomes.

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.

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.

The Impact of a Web-Based Course Concerning Patient Education for Mental Health Care Professionals: Quasi-Experimental Study

BACKGROUND

Continuing education has an important role in supporting the competence of health care professionals. Although Web-based education is a growing business in various health sectors, few studies have been conducted in psychiatric settings to show its suitability in demanding work environments.

OBJECTIVE

We aimed to describe the impact of a Web-based educational course to increase self-efficacy, self-esteem, and team climate of health care professionals. Possible advantages and disadvantages of the Web-based course are also described.

METHODS

The study used nonrandomized, pre-post intervention design in 1 psychiatric hospital (3 wards). Health care professionals (n=33) were recruited. Self-efficacy, self-esteem, and team climate were measured at 3 assessment points (baseline, 8 weeks, and 6 months). Possible advantages and disadvantages were gathered with open-ended questions at the end of the course.

RESULTS

Our results of this nonrandomized, pre-post intervention study showed that health care professionals (n=33) had higher self-efficacy after the course, and the difference was statistically significant (mean 30.16, SD 3.31 vs mean 31.77, SD 3.35; P=.02). On the other hand, no differences were found in the self-esteem or team climate of the health care professionals before and after the course. Health care professionals found the Web-based course useful in supporting their work and relationships with patients. The tight schedule of the Web-based course and challenges in recruiting patients to use the patient education program with health care professionals were found to be the disadvantages.

CONCLUSIONS

Web-based education might be a useful tool to improve the self-efficacy of health care professionals even in demanding work environments such as psychiatric hospitals. However, more studies with robust and sufficiently powered data are still needed.

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

OBJECT

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

METHOD

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

RESULT

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

E-learning for health professionals

BACKGROUND

The use of e-learning, defined as any educational intervention mediated electronically via the Internet, has steadily increased among health professionals worldwide. Several studies have attempted to measure the effects of e-learning in medical practice, which has often been associated with large positive effects when compared to no intervention and with small positive effects when compared with traditional learning (without access to e-learning). However, results are not conclusive.

OBJECTIVES

To assess the effects of e-learning programmes versus traditional learning in licensed health professionals for improving patient outcomes or health professionals' behaviours, skills and knowledge.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases and three trial registers up to July 2016, without any restrictions based on language or status of publication. We examined the reference lists of the included studies and other relevant reviews. If necessary, we contacted the study authors to collect additional information on studies.

SELECTION CRITERIA

Randomised trials assessing the effectiveness of e-learning versus traditional learning for health professionals. We excluded non-randomised trials and trials involving undergraduate health professionals.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data and assessed risk of bias. We graded the certainty of evidence for each outcome using the GRADE approach and standardised the outcome effects using relative risks (risk ratio (RR) or odds ratio (OR)) or standardised mean difference (SMD) when possible.

MAIN RESULTS

We included 16 randomised trials involving 5679 licensed health professionals (4759 mixed health professionals, 587 nurses, 300 doctors and 33 childcare health consultants).When compared with traditional learning at 12-month follow-up, low-certainty evidence suggests that e-learning may make little or no difference for the following patient outcomes: the proportion of patients with low-density lipoprotein (LDL) cholesterol of less than 100 mg/dL (adjusted difference 4.0%, 95% confidence interval (CI) -0.3 to 7.9, N = 6399 patients, 1 study) and the proportion with glycated haemoglobin level of less than 8% (adjusted difference 4.6%, 95% CI -1.5 to 9.8, 3114 patients, 1 study). At 3- to 12-month follow-up, low-certainty evidence indicates that e-learning may make little or no difference on the following behaviours in health professionals: screening for dyslipidaemia (OR 0.90, 95% CI 0.77 to 1.06, 6027 patients, 2 studies) and treatment for dyslipidaemia (OR 1.15, 95% CI 0.89 to 1.48, 5491 patients, 2 studies). It is uncertain whether e-learning improves or reduces health professionals' skills (2912 health professionals; 6 studies; very low-certainty evidence), and it may make little or no difference in health professionals' knowledge (3236 participants; 11 studies; low-certainty evidence).Due to the paucity of studies and data, we were unable to explore differences in effects across different subgroups. Owing to poor reporting, we were unable to collect sufficient information to complete a meaningful 'Risk of bias' assessment for most of the quality criteria. We evaluated the risk of bias as unclear for most studies, but we classified the largest trial as being at low risk of bias. Missing data represented a potential source of bias in several studies.

AUTHORS' CONCLUSIONS

When compared to traditional learning, e-learning may make little or no difference in patient outcomes or health professionals' behaviours, skills or knowledge. Even if e-learning could be more successful than traditional learning in particular medical education settings, general claims of it as inherently more effective than traditional learning may be misleading.

Effectiveness of a Multimodal Intervention Program for Restraint Prevention in an Acute Spanish Psychiatric Ward

BACKGROUND

International recommendations have called to implement strategies to reduce the use of coercion in psychiatric settings. However, in Spain there is a lack of research about intervention programs to reduce mechanical restraint in acute psychiatric units.

OBJECTIVE

The aim of this study was to evaluate the effectiveness of a multimodal intervention program based on the principles of six core strategies to reduce the frequency of use of mechanical restraint in an acute psychiatric ward.

DESIGN

The design was a retrospective analysis of the frequency and duration of episodes of mechanical restraint prior to the intervention program (2012) and during the intervention program (2013) in one acute psychiatric ward. The intervention was governed by four strategies: (1) leadership and organizational changes, (2) registration and monitoring of risk patients, (3) staff training, and (4) involving patients in the treatment program.

RESULTS

There was a significant difference between the mean number of monthly episodes of mechanical restraint per 1,000 patient days, pre-intervention (18.54 ± 8.78) compared with postintervention (8.53 ± 7.00; p = .005). We found the probability that mechanical restraint would occur in a hospital admission decreased after performing the intervention (odds ratio = .587; confidence interval = 0.411-0.838; p = .003) after adjusting for confounding variables. The total percentage of restrained patients fell from 15.07% to 9.74%.

CONCLUSIONS

The main implication of the study is to support the effectiveness of specific intervention programs based on different measures to reduce mechanical restraint and without contemplating all the strategies that are considered effective.

Patterns of Restraint Utilization in a Community Hospital's Psychiatric Inpatient Units

Restraint use in psychiatry has been a topic of clinical and ethical debate for years. As much as the medical community desires to attain the goal of a restraint-free environment, there are not many alternatives available when it comes to protecting the safety of violent patients and those around them. Our objective was to examine patterns of restraint use and analyze the factors leading to its use in adult psychiatric inpatient units. We conducted a retrospective review of restraint orders from January 2007 to December 2012, for inpatient units at a community mental health hospital, examining-unit, patient gender, number and duration of restraint episodes, time of day, and whether medications and/or verbal redirection were used. For the 6-year period studied, a total of 1753 restraint order-sheets were filed for 455 patients. Mixed-model regression found significant differences in duration of restraint episodes depending on: patient gender, unit, medication use, verbal redirection and AM/PM shifts. These differences were consistent over time with no significant interactions with years and remained significant when included together in an overall multivariate model. We elucidate variable patterns of restraint utilization correlating with elements such as patient gender, time of day and staff shift, medication use, and attempts at verbally redirecting the patient. Besides providing much needed data on the intricate dynamics influencing restraint use, we suggest steps to implement hospital-wide restraint-reduction initiatives including cultural changes related to restraint usage, enhanced staff-training in conflict de-escalation techniques and personalized treatment plans for foreseeable restraint episodes.

Effects of a Regulatory Protocol for Mechanical Restraint and Coercion in a Spanish Psychiatric Ward

PURPOSE

There is still limited information on what type of measures are most efficient to reduce coercion. The aim of this study was to determine if the introduction of a new regulatory protocol in a specific psychiatric ward in Andalusia (Spain) contributed to reducing the use of mechanical restraint.

DESIGN AND METHODS

The study included a comparison of two time periods: 2005 (one year before the implementation of the new regulatory protocol) and 2012, in all hospitalized patients (N=1,094). The study also analyzes with logistic regression the variables related to a shorter duration of mechanical restraint.

FINDINGS

Mechanical restraint rate per year was reduced, not significantly, from 18.2% to 15.1%. The average duration of each mechanical restraint episode was significantly reduced from 27.91 to 15.33 hr. The following variables have been associated with a shorter period of coercion: being female and the year of restraint (2012).

PRACTICE IMPLICATIONS

Specific plans are required, including different interventions, in order to achieve marked reduction in the use of coercive measures.

Impact of the creation and implementation of a clinical management guideline for personality disorders in reducing use of mechanical restraints in a psychiatric inpatient unit

OBJECTIVE

To evaluate the impact of the implementation of a guideline for the management of personality disorders on reducing the frequency of use of mechanical restraints in a psychiatric inpatient unit.

METHOD

This retrospective study was conducted in a psychiatric inpatient unit with 42 beds, which serves an urban area of 330,000 inhabitants. The sample consisted of all patients with a clinical diagnosis of personality disorder (DSM-IV-TR criteria) who were admitted to the unit from January 2010 to December 2010 and from January 2011 to December 2011 (ie, before and after, respectively, the implementation of the guideline). The guideline focused on cluster B disorders and follows a psychodynamic perspective.

RESULTS

Restraint use was reduced from 38 of 87 patients with personality disorders (43.7%) to 3 of 112 (2.7%), for a relative risk of 0.06 (95% CI, 0.02-0.19) and an absolute risk reduction of 41% (95% CI, 29.9%-51.6%). The risk of being discharged against medical advice increased after the intervention, with a relative risk of 1.84 (95% CI, 0.96-3.51). Restraint use in patients with other diagnoses was also reduced to a similar extent.

CONCLUSIONS

The use of mechanical restraints was dramatically reduced after the implementation of a clinical practice guideline on personality disorders, suggesting that these coercive measures might be decreased in psychiatric inpatient units.