1
|
Daguman EI, Hutchinson M, Lakeman R. Uncovering Complexities in Reducing Aggression, Conflict and Restrictive Practices in Acute Mental Healthcare Settings: An Overview of Reviews. Int J Ment Health Nurs 2024. [PMID: 38886873 DOI: 10.1111/inm.13376] [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] [Received: 02/04/2024] [Revised: 05/23/2024] [Accepted: 05/30/2024] [Indexed: 06/20/2024]
Abstract
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.
Collapse
Affiliation(s)
| | | | - Richard Lakeman
- Southern Cross University, Lismore, New South Wales, Australia
| |
Collapse
|
2
|
Laake ALW, Roaldset JO, Husum TL, Bjørkly SK, Gustavsen CC, Lockertsen Ø. Interrater reliability of the violence risk assessment checklist for youth: a case vignette study. BMC Psychiatry 2024; 24:303. [PMID: 38654194 DOI: 10.1186/s12888-024-05746-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 04/08/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Facilities providing health- and social services for youth are commonly faced with the need for assessment and management of violent behavior. These providers often experience shortage of resources, compromising the feasibility of conducting comprehensive violence risk assessments. The Violence Risk Assessment Checklist for Youth aged 12-18 (V-RISK-Y) is a 12-item violence risk screening instrument developed to rapidly identify youth at high risk for violent behavior in situations requiring expedient evaluation of violence risk. The V-RISK-Y instrument was piloted in acute psychiatric units for youth, yielding positive results of predictive validity. The aim of the present study was to assess the interrater reliability of V-RISK-Y in child and adolescent psychiatric units and acute child protective services institutions. METHODS A case vignette study design was utilized to assess interrater reliability of V-RISK-Y. Staff at youth facilities (N = 163) in Norway and Sweden scored V-RISK-Y for three vignettes, and interrater reliability was assessed with the intraclass correlation coefficient (ICC). RESULTS Results indicate good interrater reliability for the sum score and Low-Moderate-High risk level appraisal across staff from the different facilities and professions. For single items, interrater reliability ranged from poor to excellent. CONCLUSIONS This study is an important step in establishing the psychometric properties of V-RISK-Y. Findings support the structured professional judgment tradition the instrument is based on, with high agreement on the overall risk assessment. This study had a case vignette design, and the next step is to assess the reliability and validity of V-RISK-Y in naturalistic settings.
Collapse
Affiliation(s)
- Anniken L W Laake
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway.
- Oslo University Hospital, Centre for Research and Education in Forensic Psychiatry, Oslo, Norway.
| | - John Olav Roaldset
- Oslo University Hospital, Centre for Research and Education in Forensic Psychiatry, Oslo, Norway
| | - Tonje Lossius Husum
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway
| | - Stål Kapstø Bjørkly
- Faculty of Health Sciences and Social Care, Molde University College, Molde, Norway
| | | | - Øyvind Lockertsen
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway
- Oslo University Hospital, Centre for Research and Education in Forensic Psychiatry, Oslo, Norway
| |
Collapse
|
3
|
Dauriac-Le Masson V, El-Khoury Lesueur F, Lahaye J, Launay C, Christodoulou A, Boiteux C, Maman J, Bonnemaison X, Perquier F, Vacheron MN. Characteristics and correlates of seclusion and mechanical restraint measures in a Parisian psychiatric hospital group. Front Psychiatry 2024; 15:1296356. [PMID: 38445090 PMCID: PMC10913196 DOI: 10.3389/fpsyt.2024.1296356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 02/02/2024] [Indexed: 03/07/2024] Open
Abstract
Introduction Seclusion or restraint (S/R) are last-resort measures used in psychiatry to ensure the safety of the patient and the staff. However, they have harmful physical and psychological effects on patients, and efforts to limit their use are needed. We describe the characteristics and correlates of S/R events in four Parisian psychiatric centers. Methods Within a 3-month period, November 5, 2018 to February 3, 2019, we recorded data for patients experiencing an S/R measure as well as characteristics of the measures. We studied the mean duration of a S/R event, the time between hospital admission and the occurrence of the event, as well as correlates of these durations. We also examined factors associated with use of a restraint versus a seclusion measure. Results For the 233 patients included, we recorded 217 seclusion measures and 64 mechanical restraints. Seclusion measures mostly occurred after the patient's transfer from the emergency department. The duration of a seclusion measure was about 10 days. Patients considered resistant to psychotropic treatments more frequently had a longer seclusion duration than others. The mean duration of a mechanical restraint measure was 4 days. Male sex and younger age were associated with experiencing mechanical restraint. Discussion S/R measures mostly occur among patients perceived as resistant to psychotropic drugs who are arriving from the emergency department. Developing specific emergency department protocols might be useful in limiting the use of coercive measures.
Collapse
Affiliation(s)
| | - Fabienne El-Khoury Lesueur
- Cellule épidémiologie, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Sorbonne Universite, INSERM UMRS_1136, Institut Pierre Louis d’Epidémiologie et de Santé Publique IPLESP, Paris, France
| | - Justine Lahaye
- Cellule épidémiologie, GHU Paris Psychiatrie et Neurosciences, Paris, France
| | - Corinne Launay
- Pôle Psychiatrie Précarité, GHU Paris Psychiatrie et Neurosciences, Paris, France
| | | | | | | | | | - Florence Perquier
- Cellule épidémiologie, GHU Paris Psychiatrie et Neurosciences, Paris, France
| | | |
Collapse
|
4
|
Hirsch S, Flammer E, Steinert T. Estimating costs of bedside assessment by a judge in each case of mechanical restraint in Germany after new legislation. Front Psychiatry 2024; 14:1291130. [PMID: 38260786 PMCID: PMC10800919 DOI: 10.3389/fpsyt.2023.1291130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/05/2023] [Indexed: 01/24/2024] Open
Abstract
Background In 2018, the German Federal Constitutional Court decided that mechanical restraint is the most intrusive coercive measure and its use requires a judge's decision after bedside assessment if lasting longer than 30 min. Subsequently, legal changes were realized. The objective of our study was to determine the number of saved coercive episodes and saved hours in seclusion or restraint in 2019 compared to the average of the previous years, 2015-2017, as well as costs per saved episode, hour, and case saved from any coercive measure. Methods We used data from the Baden-Wuerttemberg case registry for coercive measures, covering all 32 psychiatric hospitals of the Federal State and 435,767 admissions in the study period. Time expenditure was calculated as 3.5 h with an average of 51.95 € per working hour on the side of the justice system and 1.5 h (45.94 €/h) on the side of the hospital per case. Results The number of coercive episodes decreased by 10.0% from 28,181 (average 2015-2017) to 25,371 (2019). The number of hours in seclusion or restraint decreased by 17.9% from 321,956 (2015-2017) to 264,423 (2019). This resulted in the cost of 872.33 € per saved episode and 42.61 € per saved hour in seclusion or restraint. Conclusion Given the correctness of our estimations, saving 1 h in coercion by less than 1 h of an expert's work might be justified from an ethical and economic perspective.
Collapse
Affiliation(s)
- Sophie Hirsch
- Centers for Psychiatry Suedwuerttemberg, Ulm University, Ravensburg-Weissenau, Germany
| | | | | |
Collapse
|
5
|
Steinert T, Baumgardt J, Bechdolf A, Bühling-Schindowski F, Cole C, Flammer E, Jaeger S, Junghanss J, Kampmann M, Mahler L, Muche R, Sauter D, Vandamme A, Hirsch S. Implementation of guidelines on prevention of coercion and violence (PreVCo) in psychiatry: a multicentre randomised controlled trial. THE LANCET REGIONAL HEALTH. EUROPE 2023; 35:100770. [PMID: 38058297 PMCID: PMC10696231 DOI: 10.1016/j.lanepe.2023.100770] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/19/2023] [Accepted: 10/20/2023] [Indexed: 12/08/2023]
Abstract
Background Interventions to prevent the use of coercion in psychiatric hospitals have been summarized in the 2018 German Association for Psychiatry, Psychotherapy, and Psychosomatic's comprehensive guidelines. Twelve recommendations for implementation of these guideline on psychiatric wards have been deducted and their feasibility has been tested in a pilot study, using external implementation consultants as facilitators. The objective of the PreVCo study was to test their effect in a randomised clinical trial. Methods Fifty-four psychiatric wards in Germany treating voluntary and involuntary patients were randomly allocated to either an intervention or to a waiting list condition. The intervention consisted of the implementation of three out of 12 suggested recommendations as selected by the ward teams, supported by external study workers. As the primary outcome measure, the number of coercive measures used per bed and month in the final 3 months of the intervention period was determined. Secondary outcomes were the cumulative duration of coercive measures used per bed and months and assaults per bed and month. Achieved guideline adherence was measured by a fidelity scale developed for this purpose during a pilot study for the PreVCo Rating Tool. After a 3-month baseline collection period under routine conditions, randomisation was done after matching wards pairwise according to frequency of coercive measures used and scores on the PreVCo Rating Tool at baseline. The duration of the intervention period was 12 months; control wards received only an initial workshop presentation of the study and completed their PreVCo ratings. We used the Wilcoxon signed rank test and the paired t-test and conducted sensitivity analyses for different periods of observation. Findings Neither the number of coercive measures used per month and bed nor their cumulative duration nor the number of assaults per bed and months differed significantly between the 27 intervention wards and the 27 control wards in the final 3 months of the intervention period. The median number of coercive measures used decreased by 45% (median 0.96 (IQR 1.34)-0.53 (IQR 0.59) from baseline until the end of the intervention period on the intervention wards and by 28% (median 0.98 (IQR 1.71)-0.71 (IQR 1.08) on waiting list wards. The PreVCo Rating Tool showed a significant improvement in intervention wards compared to control wards, indicating a successful implementation. Interpretation The study demonstrated that guideline adherence could be significantly improved by the intervention. However, there was no evidence for an effect on the frequency or duration of coercive measures used. Spill-over effects and the impact of the COVID-19 pandemic on in-patient care might have limited the effect of the intervention. Further research from robust randomised controlled trials are necessary to identify effective interventions to reduce the use of coercion in psychiatric hospitals. Funding The study was funded by the German Innovationsfonds beim Gemeinsamen Bundesausschuss (project no. 01VSF19037). The funder had no role in study design or data collection.
Collapse
Affiliation(s)
- Tilman Steinert
- Ulm University, Germany
- Centres for Psychiatry Suedwuerttemberg, Germany
| | | | | | | | | | - Erich Flammer
- Ulm University, Germany
- Centres for Psychiatry Suedwuerttemberg, Germany
| | - Susanne Jaeger
- Ulm University, Germany
- Centres for Psychiatry Suedwuerttemberg, Germany
| | | | - Marie Kampmann
- Ulm University, Germany
- Centres for Psychiatry Suedwuerttemberg, Germany
| | | | - Rainer Muche
- Ulm University, Institute of Epidemiology and Medical Biometry, Germany
| | | | | | - Sophie Hirsch
- Ulm University, Germany
- Centres for Psychiatry Suedwuerttemberg, Germany
| |
Collapse
|
6
|
Wild B, Paul C, Friederich HC. Reduction of coercion in psychiatric hospitals: how can this be achieved? THE LANCET REGIONAL HEALTH. EUROPE 2023; 35:100795. [PMID: 38058298 PMCID: PMC10696227 DOI: 10.1016/j.lanepe.2023.100795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 12/08/2023]
Affiliation(s)
- Beate Wild
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany
| | - Cinara Paul
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany
| | - Hans-Christoph Friederich
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany
| |
Collapse
|
7
|
Wullschleger A, Vandamme A, Mielau J, Heinz A, Bermpohl F, Mahler L, Montag C. Relationship between perceived coercion and perceived justification of coercive measures - secondary analysis of a randomized-controlled trial. BMC Psychiatry 2023; 23:712. [PMID: 37784077 PMCID: PMC10546675 DOI: 10.1186/s12888-023-05192-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/14/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Subjective perception of coercion has gained attention as an important outcome. However, little is known about its relation to patients' appraisal of the justification of coercive measures. The present study aims to analyze the relationship between patients' appraisal of the justification of coercive measures and their level of perceived coercion. METHODS This study presents a secondary analysis of the results of a multi-center RCT conducted to evaluate the effects of post-coercion review. Patients who experienced at least one coercive measure during their hospital stay were included in the trial. Participants' appraisal of the justification of coercive measures was categorized into patient-related and staff-related justifications. Subjective coercion was assessed using the Coercion Experience Scale (CES) and used as dependent variable in a multivariate regression model. RESULTS 97 participants who completed the CES were included in the analysis. CES scores were significantly associated with the perception of the coercive measure as justified by staff-related factors (B = 0,540, p < 0,001), as well as with higher level of negative symptoms (B = 0,265, p = 0,011), and with mechanical restraint compared to seclusion (B=-0,343, p = 0,017). CONCLUSIONS Patients' perceptions of coercive measures as justified by staff-related factors such as arbitrariness or incompetence of staff are related to higher levels of perceived coercion. Multiprofessional efforts must be made to restrict the use of coercive measures and to ensure a transparent and sustainable decision-making process, particularly with patients showing high levels of negative symptoms. Such key elements should be part of all coercion reduction programs.
Collapse
Affiliation(s)
- Alexandre Wullschleger
- Department of Psychiatry and Psychotherapy, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt- Universität Zu Berlin, Campus Charité Mitte, Berlin, Germany.
- Division of Adult Psychiatry, Department of Psychiatry, Geneva University Hospitals, Ch. Du Petit-Bel-Air 2, Thônex, 1226, Switzerland.
| | - Angelika Vandamme
- Department of Psychiatry and Psychotherapy, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt- Universität Zu Berlin, Campus Charité Mitte, Berlin, Germany
| | - Juliane Mielau
- Department of Psychiatry and Psychotherapy, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt- Universität Zu Berlin, Campus Charité Mitte, Berlin, Germany
| | - Andreas Heinz
- Department of Psychiatry and Psychotherapy, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt- Universität Zu Berlin, Campus Charité Mitte, Berlin, Germany
| | - Felix Bermpohl
- Department of Psychiatry and Psychotherapy, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt- Universität Zu Berlin, Campus Charité Mitte, Berlin, Germany
| | - Lieselotte Mahler
- Department of Psychiatry and Psychotherapy, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt- Universität Zu Berlin, Campus Charité Mitte, Berlin, Germany
- Department of Psychiatry, Clinics in the Theodor-Wenzel-Werk, Berlin, Germany
| | - Christiane Montag
- Department of Psychiatry and Psychotherapy, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt- Universität Zu Berlin, Campus Charité Mitte, Berlin, Germany
| |
Collapse
|
8
|
Meroni G, Sentissi O, Kaiser S, Wullschleger A. Treatment without consent in adult psychiatry inpatient units: a retrospective study on predictive factors. Front Psychiatry 2023; 14:1224328. [PMID: 37636826 PMCID: PMC10447976 DOI: 10.3389/fpsyt.2023.1224328] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/26/2023] [Indexed: 08/29/2023] Open
Abstract
Background Coercion is one of the most important challenges in mental health. In Switzerland, forced medication can be applied during an emergency (Art. 435 of the Civil Code) or over a longer period in case of endangerment of others or oneself (Art. 434). We aimed to analyze the predictors of this specific treatment without consent. Methods Forced medication prescriptions in the Division of Adult Psychiatry of the Geneva University Hospitals between 2018 and 2021 were retrospectively analyzed. Medication under Article 434 was the main outcome variable. Age, gender, admission mode, main diagnosis, and the Health of the Nation Outcome Scales (HoNOS) score at admission were considered as potential predictors. T-test and Pearson's chi-square test were used to compare continuous and categorical variables. A logistic regression was performed to find significant predictors of forced medication. Results Seventy-one out of 4,326 inpatients were subjected to forced medication under Art. 434. HoNOS global scores at admission were not significantly different in the forced medication group compared to the control group. Aggressive behavior was lower in the former at the univariate level. Forced medication was associated at the multivariate level with female gender, involuntary admission, and psychosis. Conclusion Women suffering from psychosis are more at risk of receiving involuntary and repeated medication. The risk of deterioration in psychosocial functioning or behavioral disorganization seems to be the main argument for this coercive measure. Future studies should focus on the patient's perception of this coercion to prevent it and improve adherence to care. Follow-up after discharge might be useful to evaluate a long-term benefit.
Collapse
Affiliation(s)
- Giulia Meroni
- Division of Adult Psychiatry, Department of Psychiatry, Geneva University Hospitals, Geneva, Switzerland
| | | | | | | |
Collapse
|
9
|
Lantta T, Duxbury J, Haines-Delmont A, Björkdahl A, Husum TL, Lickiewicz J, Douzenis A, Craig E, Goodall K, Bora C, Whyte R, Whittington R. Models, frameworks and theories in the implementation of programs targeted to reduce formal coercion in mental health settings: a systematic review. Front Psychiatry 2023; 14:1158145. [PMID: 37398581 PMCID: PMC10311067 DOI: 10.3389/fpsyt.2023.1158145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/29/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction Implementation models, frameworks and theories (hereafter tools) provide researchers and clinicians with an approach to understand the processes and mechanisms for the successful implementation of healthcare innovations. Previous research in mental health settings has revealed, that the implementation of coercion reduction programs presents a number of challenges. However, there is a lack of systematized knowledge of whether the advantages of implementation science have been utilized in this field of research. This systematic review aims to gain a better understanding of which tools have been used by studies when implementing programs aiming to reduce formal coercion in mental health settings, and what implementation outcomes they have reported. Methods A systematic search was conducted using PubMed, CINAHL, PsycINFO, Cochrane, Scopus, and Web of Science. A manual search was used to supplement database searches. Quality appraisal of included studies was undertaken using MMAT-Mixed Methods Appraisal Tool. A descriptive and narrative synthesis was formed based on extracted data. Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed in this review. Results We identified 5,295 references after duplicates were removed. Four additional references were found with a manual search. In total eight studies reported in nine papers were included in the review. Coercion reduction programs that were implemented included those that were holistic, and/or used professional judgement, staff training and sensory modulation interventions. Eight different implementation tools were identified from the included studies. None of them reported all eight implementation outcomes sought from the papers. The most frequently reported outcomes were acceptability (4/8 studies) and adaptation (3/8). With regards to implementation costs, no data were provided by any of the studies. The quality of the studies was assessed to be overall quite low. Discussion Systematic implementation tools are seldom used when efforts are being made to embed interventions to reduce coercive measures in routine mental health care. More high-quality studies are needed in the research area that also involves perspectives of service users and carers. In addition, based on our review, it is unclear what the costs and resources are needed to implement complex interventions with the guidance of an implementation tool. Systematic review registration [Prospero], identifier [CRD42021284959].
Collapse
Affiliation(s)
- Tella Lantta
- Department of Nursing Science, University of Turku, Turku, Finland
- Department of Nursing, Manchester Metropolitan University, Manchester, United Kingdom
| | - Joy Duxbury
- Department of Nursing, Manchester Metropolitan University, Manchester, United Kingdom
| | - Alina Haines-Delmont
- Department of Nursing, Manchester Metropolitan University, Manchester, United Kingdom
| | - Anna Björkdahl
- Centre for Psychiatric Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm Health Care Services, Stockholm, Sweden
| | - Tonje Lossius Husum
- Department of Health Sciences, Oslo Metropolitan University, Oslo, Norway
- Centre for Medical Ethics, University of Oslo, Oslo, Norway
| | - Jakub Lickiewicz
- Department of Health Psychology, Jagiellonian University Medical College, Krakow, Poland
| | - Athanassios Douzenis
- Second Psychiatry Department, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Elaine Craig
- Department of Nursing, Manchester Metropolitan University, Manchester, United Kingdom
| | - Katie Goodall
- Department of Nursing, Manchester Metropolitan University, Manchester, United Kingdom
| | - Christina Bora
- Second Psychiatry Department, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Rachel Whyte
- Department of Nursing, Manchester Metropolitan University, Manchester, United Kingdom
| | - Richard Whittington
- Centre for Research and Education in Security, Prisons and Forensic Psychiatry, Forensic Department Østmarka, St. Olav's Hospital, Trondheim, Norway
- Department of Mental Health, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, United Kingdom
| |
Collapse
|
10
|
Brenig D, Gade P, Voellm B. Is mental health staff training in de-escalation techniques effective in reducing violent incidents in forensic psychiatric settings? - A systematic review of the literature. BMC Psychiatry 2023; 23:246. [PMID: 37046228 PMCID: PMC10099889 DOI: 10.1186/s12888-023-04714-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 03/24/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Inpatient violence is a relevant issue in forensic psychiatric settings. Relevant guidelines recommend that restrictive measures are to be used exclusively if de-escalation and other preventive strategies have failed and there is a risk of harm to patients or staff if no action is taken. However, restrictive measures are untherapeutic and can be harmful. In order to enable staff to intervene before inpatient violence or other serious incidents occur and thus to avoid restrictive measures, mental health staff training programs including de-escalation components are being adopted in general as well as forensic mental health settings. There is growing evidence for the efficacy of mental health staff training in de-escalation techniques in the field of general psychiatry. However, there are no reviews evaluating the effectiveness of these interventions in reducing violent incidents in forensic psychiatric settings. Here we present the first literature review on the effectiveness staff training in de-escalation techniques in the field of forensic psychiatry. METHOD We searched relevant databases for original research on the effectiveness of reducing violence in forensic psychiatric settings. Studies were included if they investigated staff training programs with de-escalation techniques in forensic mental health settings. RESULTS A total of 5 relevant studies were identified. None of the studies was a randomized controlled trial. Four studies were before and after comparisons without control group. A one group post-test-only design was used in one study. Methodological quality was low. The maximum sample size was 112 participants. Results indicated no relevant impact of mental health staff training in de-escalation techniques on the rate of violent incidents in forensic psychiatric wards. However, staff seemed to feel safer following the training. Results have to be interpreted cautiously due to several methodological and content-related limitations. DISCUSSION Evidence for the effectiveness of staff training in de-escalation techniques on reducing verbal and physical aggression in forensic settings remains very limited. The existing definitions of terms like de-escalation, de-escalation training and de-escalation techniques in the healthcare context appear rather vague. Although some positive changes are reported across a variety of outcome measures it remains unclear to what extent staff training in de-esclation techniques contributes to a reduction in aggressive incidents and restrictive measures in forensic psychiatry. The clinical implications of this review are therefore limited. Yet, an important implication for future research is that a more comprehensive approach might prove worthwhile. Conducting a further review integrating a wide range of complex interventions aimed at the reduction of inpatient violence rather than focusing on de-escalation only, might be a worthwhile approach.
Collapse
Affiliation(s)
- Daniel Brenig
- Klinik für Forensische Psychiatrie, Universitätsmedizin Rostock, Rostock, Germany.
| | - Pauline Gade
- Klinik für Forensische Psychiatrie, Universitätsmedizin Rostock, Rostock, Germany
| | - Birgit Voellm
- Klinik für Forensische Psychiatrie, Universitätsmedizin Rostock, Rostock, Germany
| |
Collapse
|
11
|
Badouin J, Bechdolf A, Bermpohl F, Baumgardt J, Weinmann S. Preventing, reducing, and attenuating restraint: A prospective controlled trial of the implementation of peer support in acute psychiatry. Front Psychiatry 2023; 14:1089484. [PMID: 36824670 PMCID: PMC9941159 DOI: 10.3389/fpsyt.2023.1089484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/20/2023] [Indexed: 02/10/2023] Open
Abstract
INTRODUCTION The use of restraint as a means of managing patients is considered a critical factor that interferes with recovery. Strategies to create a less restrictive environment within psychiatric facilities are therefore eagerly sought. Peer support workers (PSWs) are increasingly employed in mental health settings. The prevailing theory is that PSWs have the potential to contribute to conflict and restraint prevention efforts in acute psychiatric wards. However, to date, research in support of this claim remains limited. OBJECTIVE The present study aimed at assessing the effectiveness of employing peer support workers with regard to reducing the use of restraint. METHODS This prospective controlled pre-post study sought to evaluate the implementation of peer support in one locked ward compared to treatment as usual (TAU) with no implementation of peer support in a second locked ward of a psychiatry department in Berlin, Germany. The pre-post comparison was planned to consist of two assessment periods of 3 months each, taking place directly before and after peer support implementation or TAU. Both assessments were extended to a period of 6 months, before and after the initially planned 12-month implementation process, in order to balance the effects of disruptions and of the COVID-19 pandemic. Using routine data, the proportion, frequency, and duration of mechanical restraint, forced medication as well as mechanical restraint in combination with forced medication, were evaluated. RESULTS In the control group, an increase in the proportion of patients subjected to measures of restraint was found between pre- and post-assessment, which was accompanied by a further increase in the mean number of events of restraint per patient within this group. In the intervention group, no significant change in the application of restraint was observed during the study period. DISCUSSION There is some indication that peer support may be protective with regard to restraint in acute wards. However, our study faced major challenges during the implementation process and the post-assessment period, such as COVID-19 and staff reorganization. This may have led to peer support not reaching its full potential. The relationship between the implementation of peer support and the use of restraint therefore merits further investigation.
Collapse
Affiliation(s)
- Julia Badouin
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Vivantes Hospital Am Urban, Vivantes Hospital im Friedrichshain, Academic Hospital, Charité-University Medicine Berlin, Berlin, Germany.,Department of Psychiatry and Neuroscience, Charité Campus Mitte Charité-University Medicine Berlin, Berlin, Germany
| | - Andreas Bechdolf
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Vivantes Hospital Am Urban, Vivantes Hospital im Friedrichshain, Academic Hospital, Charité-University Medicine Berlin, Berlin, Germany.,ORYGEN, National Centre of Excellence in Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Felix Bermpohl
- Department of Psychiatry and Neuroscience, Charité Campus Mitte Charité-University Medicine Berlin, Berlin, Germany
| | - Johanna Baumgardt
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Vivantes Hospital Am Urban, Vivantes Hospital im Friedrichshain, Academic Hospital, Charité-University Medicine Berlin, Berlin, Germany.,Wissenschaftliches Institut der AOK (WIdO), Berlin, Germany
| | - Stefan Weinmann
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Vivantes Hospital Am Urban, Vivantes Hospital im Friedrichshain, Academic Hospital, Charité-University Medicine Berlin, Berlin, Germany.,Psychiatric Hospital, Theodor-Wenzel-Werk, Berlin, Germany.,University Psychiatric Clinic (UPK), University Basel, Basel, Switzerland
| |
Collapse
|
12
|
Harpøth A, Kennedy H, Terkildsen MD, Nørremark B, Carlsen AH, Sørensen LU. Do improved structural surroundings reduce restrictive practices in psychiatry? Int J Ment Health Syst 2022; 16:53. [PMID: 36404331 PMCID: PMC9677911 DOI: 10.1186/s13033-022-00562-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 10/24/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVES There is sparse evidence that modern hospital architecture designed to prevent violence and self-harm can prevent restrictive practices (RP). We examine if the use of RPs was reduced by the structural change of relocating a 170-year-old psychiatric university hospital (UH) in Central Denmark Region (CDR) to a new modern purpose-built university hospital. METHODS The dataset includes all admissions (N = 19.567) and RPs (N = 13.965) in the self-contained CDR one year before and after the relocation of the UH. We compare RPs at the UH a year prior to and after relocation on November 16th (November 2017, November 2019) with RPs at the other psychiatric hospitals (RH) in CDR. We applied linear regression analysis to assess the development in the monthly frequency of RPs pre- and post-relocation and examine underlying trends. RESULTS At UH, RPs performed decreased from 4073 to 2585 after relocation, whereas they remained stable (from 3676 to 3631) at RH. Mechanical restraint and involuntary acute medication were aligned at both UH and RH. Using linear regression analysis, we found an overall significant decrease in the use of all restrictive practices at UH with an inclination of -9.1 observations (95% CI - 12.0; - 6.3 p < 0.0001) per month throughout the two-year follow-up. However, the decrease did not deviate significantly from the already downward trend observed one year before relocation. Similar analyses performed for RH showed a stable use of coercion. CONCLUSION The naturalistic features of the design preclude any definitive conclusion whether relocation to a new purpose-built psychiatric hospital decreased the RPs. However, we argue that improving the structural environment at the UH had a sustained effect on the already declining use of RPs, particularly mechanical restraint and involuntary acute medication.
Collapse
Affiliation(s)
- Astrid Harpøth
- grid.154185.c0000 0004 0512 597XDepartment of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Skejby, Denmark
| | - Harry Kennedy
- grid.8217.c0000 0004 1936 9705Trinity College, Dublin University, Dublin, Ireland ,National Forensic Mental Health Service, Dundrum, Ireland ,grid.7048.b0000 0001 1956 2722Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Morten Deleuran Terkildsen
- grid.154185.c0000 0004 0512 597XDepartment of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Skejby, Denmark ,grid.425869.40000 0004 0626 6125DEFACTUM, Central Denmark Region, Aarhus, Denmark
| | - Bettina Nørremark
- grid.154185.c0000 0004 0512 597XDepartment of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Skejby, Denmark
| | - Anders Helles Carlsen
- grid.154185.c0000 0004 0512 597XDepartment of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Skejby, Denmark
| | - Lisbeth Uhrskov Sørensen
- grid.154185.c0000 0004 0512 597XDepartment of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Skejby, Denmark ,grid.7048.b0000 0001 1956 2722Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| |
Collapse
|
13
|
Bramesfeld A, Röding D. Der Einfluss des Behandlungsvolumens psychiatrischer Kliniken auf das
Risiko der Anwendung besonderer Sicherungsmaßnahmen. PSYCHIATRISCHE PRAXIS 2022; 50:122-127. [PMID: 36126935 DOI: 10.1055/a-1914-8459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Zusammenfassung
Ziel Bestimmen des Einflusses des Behandlungsvolumens auf die
Häufigkeit und Dauer der Anwendung von Besonderen
Sicherungsmaßnahmen (bSm) wie Fixierung und Isolierung.
Methode Datenbasis sind krankenhausbezogene Registerdaten aus
Niedersachsen der Halbjahre 2/2019 bis 1/2021 zu Fällen,
die nach dem Niedersächsischen Gesetz für Psychisch Kranke
(NPsychKG) untergebracht sind, zum Anteil der Fälle, die eine bSm
erhielten sowie zur Anzahl und kumulativen Dauer von bSm/Fall. Es wurden
einfache lineare Regressionsmodelle gerechnet.
Ergebnis und Diskussion Mit Zunahme des Behandlungsvolumens von nach
NPsychKG untergebrachten Fällen sinkt der Anteil der Fälle, die
bSm erhalten. Dieses Ergebnis bleibt bestehen auch wenn statistische
Ausreißer aus den Berechnungen herausgelassen werden.
Schlussfolgerung Angesichts von Hinweisen, dass auch in der
psychiatrischen Versorgung das Behandlungsvolumen mit dem gewünschten
Behandlungsziel assoziiert ist, sollte das Spannungsfeld wohnortnahe
vollstationäre Versorgung in kleinen Kliniken versus Konzentration von
Expertise in Zentren diskutiert werden.
Collapse
Affiliation(s)
- Anke Bramesfeld
- Institut für Epidemiologie, Sozialmedizin und
Gesundheitssystemforschung, Medizinische Hochschule Hannover, Hannover,
Germany
| | - Dominik Röding
- Institut für Epidemiologie, Sozialmedizin und
Gesundheitssystemforschung, Medizinische Hochschule Hannover, Hannover,
Germany
| |
Collapse
|
14
|
Efkemann SA, Scholten M, Bottlender R, Juckel G, Gather J. Influence of mental health professionals' attitudes and personality traits on decision-making around coercion: Results from an experimental quantitative survey using case vignettes. Acta Psychiatr Scand 2022; 146:151-164. [PMID: 35322402 DOI: 10.1111/acps.13429] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 02/28/2022] [Accepted: 03/20/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Research on coercion in mental healthcare has recently shifted to the investigation of subjective aspects, both on the side of the people with mental disorders affected and the staff members involved. In this context, the role of personality traits and attitudes of staff members in decision-making around coercion is increasingly being assessed. This study aimed to examine the role of staff attitudes towards coercion and staff members' personality traits in decision-making around coercion in an experimental setting. METHODS We assessed the attitudes towards coercion and (general) personality traits of mental health professionals in psychiatric hospitals with a quantitative survey. Furthermore, we developed case vignettes representing cases in a 'grey zone' and included them in the survey to assess staff members' decisions about coercion in specific situations. RESULTS A general approving attitude towards coercion significantly influenced decisions around coercion in individual cases-resulting in a more likely approval of applying coercion in the cases described in the vignettes. Personality traits did not seem to be relevant in this regard. CONCLUSION Strategies to reduce coercion in mental healthcare institutions should focus more on the role of staff attitudes and encourage staff members to reflect on them critically.
Collapse
Affiliation(s)
- Simone Agnes Efkemann
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital Bochum, Ruhr University, Bochum, Germany
| | - Matthé Scholten
- Institute for Medical Ethics and History of Medicine, Ruhr University, Bochum, Germany
| | | | - Georg Juckel
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital Bochum, Ruhr University, Bochum, Germany
| | - Jakov Gather
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital Bochum, Ruhr University, Bochum, Germany.,Institute for Medical Ethics and History of Medicine, Ruhr University, Bochum, Germany
| |
Collapse
|
15
|
Välimäki M, Lam YTJ, Hipp K, Cheng PYI, Ng T, Ip G, Lee P, Cheung T, Bressington D, Lantta T. Physical Restraint Events in Psychiatric Hospitals in Hong Kong: A Cohort Register Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:6032. [PMID: 35627570 PMCID: PMC9140463 DOI: 10.3390/ijerph19106032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/07/2022] [Accepted: 05/12/2022] [Indexed: 12/22/2022]
Abstract
The need to better monitor coercion practices in psychiatric hospitals has been recognised. We aim to describe how physical restraint events occur in psychiatric hospitals and identify factors associated with physical-restraint use. A cohort register study was used. We analyzed physical restraint documents among 14 wards in two psychiatric hospitals in Hong Kong (1 July and 31 December 2018). In total, 1798 incidents occurred (the rate of physical restraint event 0.43). Typically, physically restrained patients were in early middle-age, of both genders, diagnosed with schizophrenia-spectrum and other psychotic disorders, and admitted voluntarily. Alternate methods for physical restraint were reported, such as an explanation of the situation to the patients, time-out or sedation. A longer period of being physically restrained was associated with being male, aged ≥40 years, having involuntary status, and neurodevelopmental-disorder diagnosis. Our findings support a call for greater action to promote the best practices in managing patient aggression and decreasing the use of physical restraint in psychiatric wards. The reasons for the use of physical restraint, especially for those patients who are admitted to a psychiatric hospital on a voluntary basis and are diagnosed with neurodevelopmental disorders, needs to be better understood and analysed.
Collapse
Affiliation(s)
- Maritta Välimäki
- Xiangya Center for Evidence-Based Practice & Healthcare Innovation, Central South University, Changsha 410083, China
- Department of Nursing Science, University of Turku, 20014 Turku, Finland; (Y.T.J.L.); (K.H.); (T.L.)
| | - Yuen Ting Joyce Lam
- Department of Nursing Science, University of Turku, 20014 Turku, Finland; (Y.T.J.L.); (K.H.); (T.L.)
- School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China;
| | - Kirsi Hipp
- Department of Nursing Science, University of Turku, 20014 Turku, Finland; (Y.T.J.L.); (K.H.); (T.L.)
| | - Po Yee Ivy Cheng
- Community Psychiatric Services, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR, China; (P.Y.I.C.); (T.N.)
| | - Tony Ng
- Community Psychiatric Services, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR, China; (P.Y.I.C.); (T.N.)
| | - Glendy Ip
- Central Nursing Division, Kwai Chung Hospital, Kwai Chung, Hong Kong SAR, China;
| | - Paul Lee
- Department of Health Sciences, University of Leicester, Leicester LE1 7RH, UK;
| | - Teris Cheung
- School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China;
| | - Daniel Bressington
- College of Nursing and Midwifery, Charles Darwin University, Casuarina, Larrakia Country, Darwin NT 0810, Australia;
| | - Tella Lantta
- Department of Nursing Science, University of Turku, 20014 Turku, Finland; (Y.T.J.L.); (K.H.); (T.L.)
| |
Collapse
|
16
|
Steinert T, Hirsch S, Flammer E. [Effects of the Decision of the German Constitutional Court on mechanical restraint in 2018 : Coercive measures in the psychiatric hospitals in Baden-Wuerttemberg in 2019 compared to the years 2015-2017]. DER NERVENARZT 2022; 93:706-712. [PMID: 35303128 DOI: 10.1007/s00115-022-01267-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/23/2021] [Indexed: 11/29/2022]
Abstract
On 23 July 2018 the German Constitutional Court decided that mechanical restraint in psychiatric patients with 5 or 7‑point mechanical restraint lasting longer than 30 min requires a judicial authorization. On the same day, the German Association for Psychiatry and Psychotherapy (DGPPN) published guidelines on the prevention of coercion and violence. Together, this can be considered as the strongest intervention to reduce coercion on a national level worldwide. The registry for coercive measures in the Federal State of Baden-Wuerttemberg, available since 2015 and comprising all 32 hospitals licensed to admit involuntary patients, has made it possible to evaluate the effect of the legal change. We analyzed the mean percentage of patients subjected to coercive measures and the mean cumulative duration of these interventions in ICD-10 diagnostic groups in psychiatric hospitals from 2015 to 2017 compared to 2019 among a total of 438,003 admissions. The percentage of patients subjected to any kind of freedom-restricting coercion (restraint or seclusion) decreased from 6.7% (average 2015-2017) to 5.8% in 2019 (p < 0.001). Effects were strongest in patients with organic (F0) and schizophrenic disorders (F2). The percentage of patients subjected to mechanical restraint decreased from 4.8% to 3.6% in 2019, and the percentage of mechanical restraints less than 30 min increased from 1.8% to 10.5%. Vice versa, the percentage of patients subjected to seclusion increased from 2.9% to 3.3%. The median cumulated duration of restraint and seclusion per affected case decreased from 12.7h to 10.9 h (median). The intervention was probably responsible for a reduction of the percentage of cases subjected to coercive measures by about 13% and a reduction of the duration of these measures per affected case by about 14%.
Collapse
Affiliation(s)
- Tilman Steinert
- Klinik für Psychiatrie und Psychotherapie I, Universität Ulm (Weissenau), Ravensburg, Deutschland.
- Zentren für Psychiatrie Südwürttemberg, Ravensburg, Deutschland.
- Klinik für Psychiatrie und Psychotherapie, Universität Tübingen, Tübingen, Deutschland.
- , Weingartshofer Str. 2, 88214, Ravensburg, Deutschland.
| | - Sophie Hirsch
- Klinik für Psychiatrie und Psychotherapie I, Universität Ulm (Weissenau), Ravensburg, Deutschland
- Zentren für Psychiatrie Südwürttemberg, Ravensburg, Deutschland
- Zentren für Psychiatrie Südwürttemberg, Biberach, Deutschland
| | - Erich Flammer
- Klinik für Psychiatrie und Psychotherapie I, Universität Ulm (Weissenau), Ravensburg, Deutschland
- Zentren für Psychiatrie Südwürttemberg, Ravensburg, Deutschland
| |
Collapse
|
17
|
Potthoff S, Gather J, Hempeler C, Gieselmann A, Scholten M. "Voluntary in quotation marks": a conceptual model of psychological pressure in mental healthcare based on a grounded theory analysis of interviews with service users. BMC Psychiatry 2022; 22:186. [PMID: 35296288 PMCID: PMC8928679 DOI: 10.1186/s12888-022-03810-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 02/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Psychological pressure refers to communicative strategies used by professionals and informal caregivers to influence the decision-making of service users and improve their adherence to recommended treatment or social rules. This phenomenon is also commonly referred to as informal coercion or treatment pressure. Empirical studies indicated that psychological pressure is common in mental healthcare services. No generally accepted definition of psychological pressure is available to date. A first conceptual analysis of psychological pressure focused on staff communication to promote treatment adherence and distinguished between persuasion, interpersonal leverage, inducements and threats. AIM The aim of this study was to develop a conceptual model of psychological pressure based on the perspectives of service users. METHODS Data were collected by means of semi-structured interviews. The sample consisted of 14 mental health service users with a self-reported psychiatric diagnosis and prior experience with coercion in mental healthcare. We used theoretical sampling and contacted participants via mental healthcare services and self-help groups to ensure a variety of attitudes toward the mental healthcare system in the sample. The study was conducted in Germany from October 2019 to January 2020. Data were analyzed according to grounded theory methodology. RESULTS The study indicated that psychological pressure is used not only to improve service users' adherence to recommended treatment but also to improve their adherence to social rules; that it is exerted not only by mental health professionals but also by relatives and friends; and that the extent to which service users perceive communication as involving psychological pressure depends strongly on contextual factors. Relevant contextual factors were the way of communicating, the quality of the personal relationship, the institutional setting, the material surroundings and the level of convergence between the parties' understanding of mental disorder. CONCLUSIONS The results of the study highlight the importance of staff communication training and organizational changes for reducing the use of psychological pressure in mental healthcare services.
Collapse
Affiliation(s)
- Sarah Potthoff
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Markstraße 258a, 44799, Bochum, Germany.
| | - Jakov Gather
- grid.5570.70000 0004 0490 981XInstitute for Medical Ethics and History of Medicine, Ruhr University Bochum, Markstraße 258a, 44799 Bochum, Germany ,grid.5570.70000 0004 0490 981XDepartment of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Alexandrinenstraße 1-3, 44791 Bochum, Germany
| | - Christin Hempeler
- grid.5570.70000 0004 0490 981XInstitute for Medical Ethics and History of Medicine, Ruhr University Bochum, Markstraße 258a, 44799 Bochum, Germany ,grid.5570.70000 0004 0490 981XDepartment of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Alexandrinenstraße 1-3, 44791 Bochum, Germany
| | - Astrid Gieselmann
- grid.5570.70000 0004 0490 981XInstitute for Medical Ethics and History of Medicine, Ruhr University Bochum, Markstraße 258a, 44799 Bochum, Germany ,grid.6363.00000 0001 2218 4662Department of Psychiatry, Charité_Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Matthé Scholten
- grid.5570.70000 0004 0490 981XInstitute for Medical Ethics and History of Medicine, Ruhr University Bochum, Markstraße 258a, 44799 Bochum, Germany
| |
Collapse
|
18
|
Dixon M, Long EM. An Educational Intervention to Decrease the Number of Emergency Incidents of Restraint and Seclusion on a Behavioral Health Unit. J Contin Educ Nurs 2022; 53:70-76. [PMID: 35103503 DOI: 10.3928/00220124-20220104-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The objective of this study was to implement an educational intervention on an inpatient, behavioral health care unit with the goal of reducing the number of crisis interventions of seclusion or restraint. METHOD A quasi-experimental pretest and posttest design using De-escalate Anyone, Anywhere, Anytime training was employed with a focus of an increased understanding of a range of de-escalation techniques to use instead of restraint and seclusion. RESULTS A convenience sample of 21 mental health employees participated in the training. The rates of restraint declined from a mean of 6 preintervention to 2 postintervention. The number of seclusions on the designated unit declined from a mean of 4.33 preintervention to a mean of 1.667 postintervention. CONCLUSION These data suggest that an educational intervention to increase the knowledge of direct care staff in a broad range of de-escalation techniques resulted in a reduction in the use of restraint and seclusion. Ongoing training for nursing staff may reassure them of the efficacy of alternative methods for dealing with aggressive patients. [J Contin Educ Nurs. 2022;53(2):70-76.].
Collapse
|
19
|
Montanari Vergallo G, Gulino M. Physical Restraint in Psychiatric Care: Soon to Fall Out of Use? PSYCHIAT CLIN PSYCH 2021; 31:468-473. [PMID: 38765646 PMCID: PMC11079647 DOI: 10.5152/pcp.2021.21237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 10/05/2021] [Indexed: 05/22/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Gianluca Montanari Vergallo
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, Rome, Italy
| | - Matteo Gulino
- Department of Clinical Sciences and Translational Medicine, TorVergata University of Rome, Rome, Italy
| |
Collapse
|
20
|
Flammer E, Hirsch S, Steinert T. Effect of the introduction of immediate judge's decisions in 2018 on the use of coercive measures in psychiatric hospitals in Germany: a population-based study. THE LANCET REGIONAL HEALTH. EUROPE 2021; 11:100233. [PMID: 34778858 PMCID: PMC8577163 DOI: 10.1016/j.lanepe.2021.100233] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background On 23 July 2018, the German Constitutional Court decided that mechanical restraint in psychiatric patients lasting longer than 30 minutes requires a judge's immediate decision. On the same day, the German Association for Psychiatry and Psychotherapy published its guideline on the prevention of coercion and violence. The registry for coercive measures in the federal state of Baden-Wuerttemberg, available since 2015 and comprising all 32 hospitals licensed to admit involuntary patients, has made it possible to evaluate the effect of the legal change, considered the strongest intervention ever in Germany to reduce coercion. Methods We analysed the mean percentage of patients subjected to coercive measures and the mean cumulative duration of these interventions in ICD-10 diagnostic groups in psychiatric hospitals from 2017 compared to 2019 among a total of 233,0273 admissions. Findings The percentage of patients subjected to any kind of freedom-restricting coercion decreased from 6·6% in 2017 to 5·8% in 2019 (p = 0·000). Accordingly, the percentage of patients subjected to mechanical restraint decreased from 4·8% to 3·6% in 2019 (p = 0·000). At the same time, the percentage of patients subjected to seclusion increased from 2·9% to 3·3% (p = 0·000). The median cumulated duration of restraint and seclusion per affected case decreased from 12·5 to 11·9 hrs (p = 0·001). Interpretation There is clear evidence that a strong legal intervention was effective in reducing the use of coercive measures under routine conditions. Funding The registry is funded by the Ministry of Social Welfare and Integration.
Collapse
Affiliation(s)
- Erich Flammer
- Clinic for Psychiatry and Psychotherapy I, Ulm University.,Centres for Psychiatry Suedwuerttemberg, Ravensburg, Germany
| | - Sophie Hirsch
- Clinic for Psychiatry and Psychotherapy I, Ulm University.,Centres for Psychiatry Suedwuerttemberg, Ravensburg, Germany.,Tuebingen University, Dept Neurology
| | - Tilman Steinert
- Clinic for Psychiatry and Psychotherapy I, Ulm University.,Centres for Psychiatry Suedwuerttemberg, Ravensburg, Germany.,Tuebingen University, Dept Psychiatry
| |
Collapse
|
21
|
[Association between substance use and coercive measures on psychiatric wards]. DER NERVENARZT 2021; 93:442-449. [PMID: 34491377 PMCID: PMC9061692 DOI: 10.1007/s00115-021-01181-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The intention to minimize coercive measures requires a comprehensive understanding of the influencing factors. The aim of the present work was to examine the association between substance use and the use of coercive measures. METHODS All coercive measures carried out on acute psychiatric wards of the Charité Campus Mitte in 2019 were examined, with a particular focus on the association with substance use disorders. RESULTS In 106 cases (92 patients) out of a total of 1232 cases (1131 patients), coercive measures were used, mainly admissions according to PsychKG (94) and BGB (21), more rarely isolation (23) or mechanical restraint (18). Acute intoxication was present in approximately one third of cases with coercive measures and a history of substance use disorder in two thirds, most often with alcohol and/or cannabis. In contrast, 9% of 1232 treatment cases presented with acute intoxication and 36% with substance use disorders in general. CONCLUSION The present work delivers empirical data confirming the clinically known association between intoxication and the use of coercive measures.
Collapse
|
22
|
Baar I, Schmitz-Buhl M, Gouzoulis-Mayfrank E. [Cologne Questionnaire on Attitudes Towards Coercive Measures (KEZ)]. PSYCHIATRISCHE PRAXIS 2021; 49:322-328. [PMID: 34433213 DOI: 10.1055/a-1515-2268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To develop a psychometric instrument for the assessment of the attitude of psychiatric staff towards the use of coercion. METHODS Based on a literature search, interviews (37 open questions) were carried out by representatives each of doctors and nurses. A first version was developed, all doctors and nurses in a psychiatric clinic were asked to answer the questionnaire anonymously. RESULTS 226 employees took part (response rate 32.3 %). A test-theoretical analysis led to a 39 item set with a high consistency of the overall scale (Cronbach's α =0 .904) and three factors: 1) Acceptance of coercive measures without questioning (Cronbach's α = 0.797); 2) Meaningfulness and legitimation of coercive measures (Cronbach's α = 0.812); and 3) Security and order through coercive measures (Cronbach's α = 0.791). CONCLUSIONS With the KEZ an instrument is available that holistically presents the various aspects of the attitudes of psychiatric staff to the use of coercion.
Collapse
Affiliation(s)
- Immanuel Baar
- LVR-Klinik Köln, Akademisches Lehrkrankenhaus der Universität
| | | | - Euphrosyne Gouzoulis-Mayfrank
- LVR-Klinik Köln, Akademisches Lehrkrankenhaus der Universität.,LVR-Institut für Forschung und Bildung: LVR-Institut für Versorgungsforschung
| |
Collapse
|
23
|
Mann K, Gröschel S, Singer S, Breitmaier J, Claus S, Fani M, Rambach S, Salize HJ, Lieb K. Evaluation of coercive measures in different psychiatric hospitals: the impact of institutional characteristics. BMC Psychiatry 2021; 21:419. [PMID: 34419009 PMCID: PMC8380405 DOI: 10.1186/s12888-021-03410-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/05/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Epidemiological studies have demonstrated considerable differences in the use of coercive measures among psychiatric hospitals; however, the underlying reasons for these differences are largely unclear. We investigated to what extent these differences could be explained by institutional factors. METHODS Four psychiatric hospitals with identical responsibilities within the mental health care system, but with different inpatient care organizations, participated in this prospective observational study. We included all patients admitted over a period of 24 months who were affected by mechanical restraint, seclusion, or compulsory medication. In addition to the patterns of coercive measures, we investigated the effect of each hospital on the frequency of compulsory medication and the cumulative duration of mechanical restraint and seclusion, using multivariate binary logistic regression. To compare the two outcomes between hospitals, odds ratios (OR) with corresponding 95% confidence intervals (CI) were calculated. RESULTS Altogether, coercive measures were applied in 1542 cases, corresponding to an overall prevalence of 8%. The frequency and patterns of the modalities of coercive measures were different between hospitals, and the differences could be at least partially related to institutional characteristics. For the two hospitals that had no permanently locked wards, certain findings were particularly noticeable. In one of these hospitals, the probability of receiving compulsory medication was significantly higher compared with the other institutions (OR 1.9, CI 1.1-3.0 for patients < 65 years; OR 8.0, CI 3.1-20.7 for patients ≥65 years); in the other hospital, in patients younger than 65 years, the cumulative duration of restraint and seclusion was significantly longer compared with the other institutions (OR 2.6, CI 1.7-3.9). CONCLUSIONS The findings are compatible with the hypothesis that more open settings are associated with a more extensive use of coercion. However, due to numerous influencing factors, these results should be interpreted with caution. In view of the relevance of this issue, further research is needed for a deeper understanding of the reasons underlying the differences among hospitals.
Collapse
Affiliation(s)
- Klaus Mann
- Department of Psychiatry and Psychotherapy, University Medical Center, Untere Zahlbacher Str. 8, 55131, Mainz, Germany.
| | - Sonja Gröschel
- grid.410607.4Department of Psychiatry and Psychotherapy, University Medical Center, Untere Zahlbacher Str. 8, 55131 Mainz, Germany ,grid.410607.4Department of Neurology, University Medical Center, Mainz, Germany
| | - Susanne Singer
- grid.410607.4Department of Psychiatry and Psychotherapy, University Medical Center, Untere Zahlbacher Str. 8, 55131 Mainz, Germany ,grid.410607.4Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Mainz, Germany
| | - Jörg Breitmaier
- Department of Psychiatry and Psychotherapy, Krankenhaus Zum Guten Hirten, Ludwigshafen, Germany
| | - Sylvia Claus
- Department of Psychiatry, Psychosomatics und Psychotherapy, Pfalzklinikum, Klingenmünster, Germany
| | - Markus Fani
- Department of Geriatric Psychiatry, Psychosomatics und Psychotherapy, Pfalzklinikum, Klingenmünster, Germany
| | - Stephan Rambach
- Clinic for Psychiatry and Psychotherapy, Municipal Hospital, Pirmasens, Germany
| | - Hans-Joachim Salize
- grid.413757.30000 0004 0477 2235Central Institute of Mental Health, Medical Faculty Mannheim / Heidelberg University, Mannheim, Germany
| | - Klaus Lieb
- grid.410607.4Department of Psychiatry and Psychotherapy, University Medical Center, Untere Zahlbacher Str. 8, 55131 Mainz, Germany
| |
Collapse
|
24
|
Krieger E, Fischer R, Moritz S, Nagel M. [Post-seclusion/post-restraint debriefing with patients-overview and current situation]. DER NERVENARZT 2021; 92:44-49. [PMID: 32725493 DOI: 10.1007/s00115-020-00969-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Research on measures to prevent or reduce the use of coercive measures is steadily gaining momentum in research. Post-seclusion/post-restraint debriefings with the affected patients are recommended in treatment guidelines but the effectiveness as an intervention has so far only scarcely been studied. AIMS AND METHODS This article briefly outlines the existing literature on post-seclusion/post-restraint debriefings, the legal basis in Germany, recommendations by various treatment guidelines as well as the existing evidence of the effectiveness. Furthermore, challenges pertaining to the implementation of debriefings are discussed. RESULTS Various treatment guidelines recommend post-seclusion/post-restraint debriefings with patients and the individual Mental Health Laws (PsychKG) of the German federal states provide more or less specific guidance on how to implement the intervention. So far, hardly any scientific studies on the effectiveness of post-seclusion/post-restraint debriefings exist but they are already carried out in a variety of complex treatment concepts. Various parameters, e.g. who participates and when the debriefing is conducted, also vary across implementations. Initial pilot studies have shown indications for positive effects in terms of reducing coercive measures through the implementation of post-seclusion/post-restraint debriefings; however, structured debriefings are not yet part of routine practice. CONCLUSION Structured post-seclusion/post-restraint debriefings with patients constitute a possible intervention to reduce coercive measures, but as of now there is little scientific evidence for the efficacy. Incorporating them into complex therapeutic treatment concepts for ward programs appears to be meaningful.
Collapse
Affiliation(s)
- Eva Krieger
- Klinik für Psychiatrie und Psychotherapie, Asklepios Klinik Nord - Wandsbek, Jüthornstraße 71, 22043, Hamburg, Deutschland. .,Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Deutschland.
| | - Rabea Fischer
- Klinik für Psychiatrie und Psychotherapie, Asklepios Klinik Nord - Wandsbek, Jüthornstraße 71, 22043, Hamburg, Deutschland.,Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Deutschland
| | - Steffen Moritz
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Deutschland
| | - Matthias Nagel
- Klinik für Psychiatrie und Psychotherapie, Asklepios Klinik Nord - Wandsbek, Jüthornstraße 71, 22043, Hamburg, Deutschland.,Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| |
Collapse
|
25
|
Eisele F, Flammer E, Steinert T. Incidents of aggression in German psychiatric hospitals: Is there an increase? PLoS One 2021; 16:e0245090. [PMID: 33400702 PMCID: PMC7785246 DOI: 10.1371/journal.pone.0245090] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/22/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION In a meta-analysis of international studies, 17% of admitted patients in psychiatric hospitals had exhibited violent behavior toward others. Reported data from studies in Germany were considerably lower until recent years. However, studies examining only single hospitals, as well as the quality of the data itself, have raised questions as to the validity of these findings. Indeed, a debate currently exists as to whether there has, in fact, been an increase of violent incidents in German mental institutions. METHODS In a group of 10 hospitals serving about half the population of the Federal State of Baden-Wuerttemberg with 11 million inhabitants, the Staff Observation Aggression Scale-Revised (SOAS-R) was introduced into patients' electronic charts as part of routine documentation. Data recording was strongly supported by staff councils and unions. A completed data set is now available for the year 2019. For one hospital, data are available since 2006. Due to some doubts with respect to fully covering self-directed aggression, we restricted the analysis to aggression toward others and toward objects. RESULTS In 2019, 17,599 aggressive incidents were recorded in 64,367 admissions (1,660 staying forensic psychiatric inpatients included). 5,084 (7.90%) of the admitted cases showed aggressive behavior toward others. Variation between hospitals was low to modest (SD = 1.50). The mean SOAS-R score was 11.8 (SD between hospitals 1.20%). 23% of the incidents resulted in bodily harm. The percentage of patients showing violent behavior was highest among patients with organic disorders (ICD-10 F0) and lowest among patients with addictive or affective disorders (F1, F3, F4). Forensic psychiatry had the highest proportion of cases with aggressive behavior (20.54%), but the number of incidents per bed was lower than in general adult psychiatry and child and adolescent psychiatry (indicating a lower risk for staff). In the hospital with longer-term recordings available, an increase could be observed since 2010, with considerable variation between years. CONCLUSIONS This is the most robust estimate of the frequency of violent incidents in German psychiatric hospitals thus far. The incidence is about half of what has been reported internationally, probably due to sample selection bias in previous studies and a relatively high number of hospital beds in Germany. Available data suggest an increase of violent incidents over the last ten years; however, it is unclear to which extent this is due to increased reporting.
Collapse
Affiliation(s)
- Frank Eisele
- Centers for Psychiatry Suedwuerttemberg, Ravensburg, Germany
| | - Erich Flammer
- Clinic for Psychiatry and Psychotherapy I, Ulm University, Ulm, Germany
| | - Tilman Steinert
- Clinic for Psychiatry and Psychotherapy I, Ulm University, Ulm, Germany
- * E-mail:
| |
Collapse
|
26
|
Steinert T, Hirsch S, Goebel R, Snellgrove B, Flammer E. Reduction of coercive measures under routine conditions in psychiatric hospitals 2004-2019: Strong effects in old age psychiatry, much less in general psychiatry. Eur Psychiatry 2020; 63:e102. [PMID: 33213539 PMCID: PMC8057408 DOI: 10.1192/j.eurpsy.2020.104] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Many interventions to reduce the use of seclusion and restraint have been suggested in the last decades. Evidence-based interventions in old age psychiatry are different from those in general psychiatry. A common database for psychiatric hospitals introduced in 2004 allowed to examine the use of seclusion and restraint over 16 years under routine conditions. Methods A registry for coercive measures in the Federal State of Baden-Wuerttemberg has been available since 2015, and comprises all 32 hospitals licensed to admit involuntary patients. A study group had collected data prospectively since 2004 from a subsample of these hospitals. We analyzed the mean percentage of patients subjected to coercive measures and the mean cumulative duration of these interventions in ICD-10 diagnostic groups in psychiatric hospitals from 2004 to 2019 among a total of 1,038,239 admissions. Results The proportion of cases affected by coercive measures dropped significantly from 28.4 to 10.5% in patients with ICD-10 F0 disorders, while rates in patients with other diagnoses decreased insignificantly from 7.0 to 5.4%. The cumulated duration of coercive measures per affected case also dropped significantly among patients with F0 disorders, while changes in patients with other diagnoses remained insiginficant. Conclusions The use of coercive measures in patients with organic disorders could be reduced by about 50% in a State of 11 million inhabitants within 15 years, while in contrast no substantial reduction occurred among all other diagnostic groups. Specific interventions to reduce coercive interventions seem to be particularly successful for this patient group.
Collapse
Affiliation(s)
- Tilman Steinert
- Clinic for Psychiatry I, Ulm University, Ulm, Germany.,Centres for Psychiatry Suedwuerttemberg, Ravensburg, Germany
| | - Sophie Hirsch
- Clinic for Psychiatry I, Ulm University, Ulm, Germany.,Centres for Psychiatry Suedwuerttemberg, Ravensburg, Germany.,Department of Neurology, University of Tübingen, Tübingen, Germany
| | - Rita Goebel
- Clinic for Psychiatry I, Ulm University, Ulm, Germany.,Centres for Psychiatry Suedwuerttemberg, Ravensburg, Germany
| | - Brendan Snellgrove
- Clinic for Psychiatry I, Ulm University, Ulm, Germany.,Centres for Psychiatry Suedwuerttemberg, Ravensburg, Germany
| | - Erich Flammer
- Clinic for Psychiatry I, Ulm University, Ulm, Germany.,Centres for Psychiatry Suedwuerttemberg, Ravensburg, Germany
| |
Collapse
|
27
|
Hoffmann U, Clemens V, König E, Brähler E, Fegert JM. Violence against children and adolescents by nursing staff: prevalence rates and implications for practice. Child Adolesc Psychiatry Ment Health 2020; 14:43. [PMID: 33292414 PMCID: PMC7648387 DOI: 10.1186/s13034-020-00350-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/23/2020] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND International studies show that child maltreatment is a widespread but often underestimated problem that causes high individual, social and economic costs. Child maltreatment is an important topic for the medical sector as well. On the one hand, affected persons often seek support and help from healthcare professionals, but on the other hand, assaults can also occur in medical institutions by healthcare professionals. Surprisingly, there is hardly any data on the frequency of child maltreatment by healthcare professionals in general and particularly by nursing staff. METHODS Therefore, in a large representative survey of the German population of 2,516 subjects aged between 14 and 91, the experience of child maltreatment in medical institutions by nursing staff was assessed retrospectively. RESULTS Of the 46 subjects who had an inpatient stay in a child and adolescent psychiatry before the age of 18, 33.3% reported to have experienced maltreatment by nursing staff, while 17.3% of the 474 persons who had an inpatient stay in general or pediatric hospitals experienced maltreatment by nursing staff. All forms of maltreatment were significantly more frequent in psychiatric compared to general and pediatric hospitals. CONCLUSIONS The results of our representative retrospective survey demonstrate that maltreatment by nursing staff are not rare individual cases, but that medical facilities bear systemic risks for assault. Therefore, it is necessary that all medical institutions, in particular psychiatric hospitals, address this issue. In order to reduce the risk for assaults, it is important not only to implement structural measures but also to develop an attitude that emphasizes zero tolerance for violence against children and adolescents.
Collapse
Affiliation(s)
- Ulrike Hoffmann
- Department for Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89073, Ulm, Germany.
| | - Vera Clemens
- grid.6582.90000 0004 1936 9748Department for Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89073 Ulm, Germany
| | - Elisa König
- grid.6582.90000 0004 1936 9748Department for Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89073 Ulm, Germany
| | - Elmar Brähler
- grid.410607.4Department for Psychosomatic Medicine and Psychotherapy, University Medical Center of Johannes Gutenberg University of Mainz, Maniz, Germany ,grid.9647.c0000 0004 7669 9786Department of Medical Psychology and Medical Sociology, University of Leipzig, Leipzig, Germany
| | - Jörg M. Fegert
- grid.6582.90000 0004 1936 9748Department for Child and Adolescent Psychiatry/Psychotherapy, University of Ulm, Steinhövelstr. 5, 89073 Ulm, Germany
| |
Collapse
|
28
|
Fernández-Costa D, Gómez-Salgado J, Fagundo-Rivera J, Martín-Pereira J, Prieto-Callejero B, García-Iglesias JJ. Alternatives to the Use of Mechanical Restraints in the Management of Agitation or Aggressions of Psychiatric Patients: A Scoping Review. J Clin Med 2020; 9:jcm9092791. [PMID: 32872463 PMCID: PMC7565407 DOI: 10.3390/jcm9092791] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/22/2020] [Accepted: 08/26/2020] [Indexed: 11/17/2022] Open
Abstract
Coercive measures are a highly controversial issue in mental health. Although scientific evidence on their impact is limited, they are frequently used. Furthermore, they lead to a high number of ethical, legal, and clinical repercussions on both patients, and professionals and institutions. This review aims to assess the impact of the main alternative measures to prevent or limit the use of coercive measures with restraints in the management of agitated psychiatric patients. The research was conducted following the guidelines recommended by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) in Medline, Cochrane Library, CINAHL, Web of Science, PsycInfo, LILACS, and Health Database of records between 2015 and 2020. After a critical reading, 21 valid articles were included. Both simple interventions and complex restraint programs were evaluated. Training in de-escalation techniques, risk assessment, and implementation of the “six core strategies” or “Safewards” program were the most assessed and effective interventions to reduce aggressive behaviors and the use of coercive measures. According to the revised literature, it is possible to reduce the use of restraints and coercive measures and not increase the number of incidents and violent behaviors among the patients through a non-invasive and non-pharmacological approach. However, further research and further randomized clinical trials are needed to compare the different alternatives and provide higher quality evidence.
Collapse
Affiliation(s)
| | - Juan Gómez-Salgado
- Faculty of Labour Sciences, Department of Sociology, Social Work and Public Health, University of Huelva, 21007 Huelva, Spain;
- Safety and Health Postgraduate Programme, Universidad Espíritu Santo, Guayaquil 091650, Ecuador
- Correspondence: ; Tel.: +34-959-219700
| | - Javier Fagundo-Rivera
- Andalusian Health Service, Primary Care Emergency Service, Health Sciences Doctorate School, University of Huelva, 21007 Huelva, Spain;
| | - Jorge Martín-Pereira
- Hospital Transport Consortium, Isla Cristina Health Center, Isla Cristina, 21410 Huelva, Spain;
| | | | - Juan Jesús García-Iglesias
- Faculty of Labour Sciences, Department of Sociology, Social Work and Public Health, University of Huelva, 21007 Huelva, Spain;
| |
Collapse
|
29
|
Günther MP, Kirchebner J, Lau S. Identifying Direct Coercion in a High Risk Subgroup of Offender Patients With Schizophrenia via Machine Learning Algorithms. Front Psychiatry 2020; 11:415. [PMID: 32477188 PMCID: PMC7237713 DOI: 10.3389/fpsyt.2020.00415] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/23/2020] [Indexed: 11/13/2022] Open
Abstract
PURPOSE This study aims to explore risk factors for direct coercive measures (seclusion, restraint, involuntary medication) in a high risk subpopulation of offender patients with schizophrenia spectrum disorders. METHODS Five hundred sixty nine potential predictor variables were explored in terms of their predictive power for coercion/no coercion in a set of 131 (36.6%) offender patients who experienced coercion and 227 who did not, using machine learning analysis. The dataset was split (70/30%) applying variable filtering, machine learning model building, and selection embedded in nested resampling approach in one subset. The best model was then selected, and the most important variables extracted on the second data subset. RESULTS In the final model the following variables identified coercion with a balanced accuracy of 73.28% and a predictive power (area under the curve, AUC) of 0.8468: threat of violence, (actual) violence toward others, the application of direct coercive measures during past psychiatric inpatient treatments, the positive and negative syndrome scales (PANSS) poor impulse control, uncooperativeness, and hostility and the total PANSS-score at admission, prescription of haloperidol during inpatient treatment, the daily cumulative olanzapine equivalent antipsychotic dosage at discharge, and the legal prognosis estimated by a team of licensed forensic psychiatrists. CONCLUSIONS Results confirm prior findings, add detail on factors indicative for the use of direct coercion, and provide clarification on inconsistencies. Limitations, clinical relevance, and avenues for future research are discussed.
Collapse
Affiliation(s)
- Moritz Philipp Günther
- Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry Zurich, Zurich, Switzerland
| | - Johannes Kirchebner
- Department of Forensic Psychiatry, University Hospital of Psychiatry Zurich, Zurich, Switzerland
| | - Steffen Lau
- Department of Forensic Psychiatry, University Hospital of Psychiatry Zurich, Zurich, Switzerland
| |
Collapse
|
30
|
Steinert T. [First conclusions from the register for coercive measures in Baden-Württemberg]. DER NERVENARZT 2019; 90:956-957. [PMID: 31420691 DOI: 10.1007/s00115-019-0784-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- T Steinert
- Klinik für Psychiatrie und Psychotherapie I der Universität Ulm, Zentrum für Psychiatrie Südwürttemberg, Weingartshofer Str. 2, 88214, Ravensburg-Weissenau, Deutschland.
| |
Collapse
|
31
|
Efkemann SA, Bernard J, Kalagi J, Otte I, Ueberberg B, Assion HJ, Zeiß S, Nyhuis PW, Vollmann J, Juckel G, Gather J. Ward Atmosphere and Patient Satisfaction in Psychiatric Hospitals With Different Ward Settings and Door Policies. Results From a Mixed Methods Study. Front Psychiatry 2019; 10:576. [PMID: 31543830 PMCID: PMC6728825 DOI: 10.3389/fpsyt.2019.00576] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/22/2019] [Indexed: 11/22/2022] Open
Abstract
Background: Open-door policies in psychiatry are discussed as a means to improve the treatment of involuntarily committed patients in various aspects. Current research on open-door policies focuses mainly on objective effects, such as the number of coercive interventions or serious incidents. The aim of the present study was to investigate more subjective perceptions of different psychiatric inpatient settings with different door policies by analyzing ward atmosphere and patient satisfaction. Methods: Quantitative data on the ward atmosphere using the Essen Climate Evaluation Scale (EssenCES) and on patient satisfaction (ZUF-8) were obtained from involuntarily committed patients (n = 81) in three psychiatric hospitals with different ward settings and door policies (open, facultative locked, locked). Furthermore, qualitative interviews with each of 15 patients, nurses, and psychiatrists were conducted in one psychiatric hospital with a facultative locked ward comparing treatment in an open vs. a locked setting. Results: Involuntarily committed patients rated the EssenCES' subscale "Experienced Safety" higher in an open setting compared with a facultative locked and a locked setting. The subscale "Therapeutic Hold" was rated higher in an open setting than a locked setting. Regarding the safety experienced from a mental health professionals' perspective, the qualitative interviews further revealed advantages and disadvantages of door locking in specific situations, such as short-term de-escalation vs. increased tension. Patient satisfaction did not differ between the hospitals but correlated weakly with the EssenCES' subscale "Therapeutic Hold." Conclusion: Important aspects of the ward atmosphere seem to be improved in an open vs. a locked setting, whereas patient satisfaction does not seem to be influenced by the door status in the specific population of patients under involuntary commitment. The ward atmosphere turned out to be more sensitive to differences between psychiatric inpatient settings with different door policies. It can contribute to a broader assessment by including subjective perceptions by those who are affected directly by involuntary commitments. Regarding patient satisfaction under involuntary commitment, further research is needed to clarify both the relevance of the concept and its appropriate measurement.
Collapse
Affiliation(s)
- Simone Agnes Efkemann
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Johannes Bernard
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Janice Kalagi
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Ina Otte
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Bianca Ueberberg
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany.,LWL-Klinik Dortmund, Psychiatrie, Psychotherapie, Psychosomatische Medizin, Rehabilitation, Dortmund, Germany
| | - Hans-Jörg Assion
- LWL-Klinik Dortmund, Psychiatrie, Psychotherapie, Psychosomatische Medizin, Rehabilitation, Dortmund, Germany
| | - Swantje Zeiß
- Klinik für Psychiatrie, Psychotherapie und Psychosomatik, St. Marien Hospital Eickel, Herne, Germany
| | - Peter W Nyhuis
- Klinik für Psychiatrie, Psychotherapie und Psychosomatik, St. Marien Hospital Eickel, Herne, Germany
| | - Jochen Vollmann
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Georg Juckel
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Jakov Gather
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany.,Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| |
Collapse
|