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Belayneh Z, Chavulak J, Lee DCA, Petrakis M, Haines TP. Prevalence and variability of restrictive care practice use (physical restraint, seclusion and chemical restraint) in adult mental health inpatient settings: A systematic review and meta-analysis. J Clin Nurs 2024; 33:1256-1281. [PMID: 38304928 DOI: 10.1111/jocn.17041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 11/15/2023] [Accepted: 01/07/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND There is a growing consensus to reduce the use of restrictive care practices in mental health settings to minimise the physical and psychological complications for patients. However, data regarding restrictive care practice use and factors contributing to variations in the proportion estimates has not previously been synthesised. AIMS This study aimed to synthesise evidence on (1) the pooled proportions of physical restraint, seclusion or chemical restraint in adult mental health inpatients and (2) sources of variability in these proportion estimates. METHODS Studies were identified from Scopus, MEDLINE, PsycINFO, Web of Science, Embase and CINAHL databases following the PRISMA 2020 guidelines. We conducted a meta-analysis of studies published in English language from 1 January 2010 to 15 August 2022. Binomial data were pooled using a random effect model, with 95% confidence intervals. Meta-regression was also computed to identify factors that may contribute to variations in the proportion estimates. RESULTS A total of 77 studies were included in this meta-analysis. The pooled prevalence of physical restraint, seclusion and chemical restraint was 14.4%, 15.8% and 25.7%, respectively. Data were heterogeneous across studies (I2 > 99%). Reporting practices and geographical locations contributed to the variability in the reported estimates of restrictive care practices, with studies from Asian countries reporting higher proportions. CONCLUSION There appear differences between geographical locations in the proportion of restrictive practices in mental health inpatients; however, this is complicated by how these prevalence data have been measured and defined. Consistency in the reporting of restrictive care practices in mental health is required to make valid comparisons between geographical regions, policy settings and practice innovations. RELEVANCE TO CLINICAL PRACTICE Efforts are needed to develop training programmes and policy changes to ensure consistency in defining and reporting of restrictive care practices in mental health facilities. PATIENT/PUBLIC CONTRIBUTION This is a systematic review that analysed data from previously published studies, and there was no patient/public contribution in this study. PROTOCOL REGISTRATION The protocol for this review has been registered to PROSPERO: CRD42022335167.
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Affiliation(s)
- Zelalem Belayneh
- Faculty of Medicine, Nursing and Health Sciences, School of Primary and Allied Health Care, Monash University Peninsula Campus, Melbourne, Victoria, Australia
- Department of Psychiatry, College of Health, and Medical Sciences, Dilla University, Dila, Ethiopia
| | - Jacinta Chavulak
- Faculty of Medicine, Nursing and Health Sciences, School of Primary and Allied Health Care, Monash University Peninsula Campus, Melbourne, Victoria, Australia
| | - Den-Ching A Lee
- Faculty of Medicine, Nursing and Health Sciences, School of Primary and Allied Health Care, Monash University Peninsula Campus, Melbourne, Victoria, Australia
- Rehabilitation, Ageing and Independent Living (RAIL) Research Centre, Monash University (Peninsula Campus), Frankston, Victoria, Australia
- National Centre for Healthy Ageing, Monash University, Frankston, Victoria, Australia
| | - Melissa Petrakis
- Faculty of Medicine, Nursing and Health Sciences, School of Primary and Allied Health Care, Monash University Peninsula Campus, Melbourne, Victoria, Australia
- St Vincent's Hospital Mental Health Service, Melbourne, Victoria, Australia
| | - Terry P Haines
- Faculty of Medicine, Nursing and Health Sciences, School of Primary and Allied Health Care, Monash University Peninsula Campus, Melbourne, Victoria, Australia
- National Centre for Healthy Ageing, Monash University, Frankston, Victoria, Australia
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Baggio S, Kaiser S, Wullschleger A. Effect of Seclusion on Mental Health Status in Hospitalized Psychiatric Populations: A Trial Emulation using Observational Data. Eval Health Prof 2024; 47:3-10. [PMID: 36898680 PMCID: PMC10858627 DOI: 10.1177/01632787231164489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
The use of coercive practices, i.e., interventions against a person's will, is controversial. Recent observational studies highlighted their potential detrimental effects on patients' mental health, but this topic remains understudied. This study investigated the effect of a common coercive practice, seclusion (i.e., being locked in a closed room), on mental health using a trial emulation of observational data to allow causal inference. We used data from 1200 psychiatric inpatients, classified as being either secluded or non-secluded during their hospital stay. Inverse probability of treatment weighting was used to emulate the random assignment to the intervention. The primary outcome was the Health of the Nations Outcome Scales (HoNOS). The secondary outcome was the first item of the HoNOS, which focuses on overactive, aggressive, disruptive, or agitated behavior. Both outcomes were assessed at hospital discharge. There was a significant effect of seclusion with increases in both total HoNOS score (p = .002) and item 1 of the HoNOS (p = .01). Seclusion may have a negative causal effect of patients' mental health status and should therefore be avoided in mental health care settings. Training efforts should raise the awareness of the medical staff about potential adverse effects instead of therapeutic benefits.
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Affiliation(s)
- Stéphanie Baggio
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Division of Prison Health, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Stefan Kaiser
- Adult Psychiatry Division, Department of Psychiatry, Geneva University Hospitals, Geneva, Switzerland
| | - Alexandre Wullschleger
- Adult Psychiatry Division, Department of Psychiatry, Geneva University Hospitals, Geneva, Switzerland
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Quinn M, Jutkowitz E, Primack J, Lenger K, Rudolph J, Trikalinos T, Rickard T, Mai HJ, Balk E, Konnyu K. Protocols to reduce seclusion in inpatient mental health units. Int J Ment Health Nurs 2024. [PMID: 38193620 DOI: 10.1111/inm.13277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/04/2023] [Indexed: 01/10/2024]
Abstract
The use of seclusion to manage conflict behaviours in psychiatric inpatient settings is increasingly viewed as an intervention of last resort. Many protocols have, thus, been developed to reduce the practice. We conducted a systematic review to determine the effectiveness of protocols to reduce seclusion on process outcomes (e.g., seclusion, restraint), patient outcomes (e.g., injuries, aggressive incidents, satisfaction), and staff outcomes (e.g., injuries, satisfaction). We searched Medline, Embase, the Cochrane Register of Clinical Trials, PsycINFO, CINAHL, cairn.info, and ClinicalTrials.gov for protocols to reduce seclusion practices for adult patients on inpatient mental health units (from inception to September 6, 2022). We summarised and categorised reported elements of the protocols designed to reduce seclusion using the Behaviour Change Wheel Intervention Functions and resources needed to implement the protocol in psychiatric units. We assessed risk of bias and determined certainty of evidence using GRADE. Forty-eight reports addressed five approaches to reduce seclusion: hospital/unit restructuring (N = 4), staff education/training (N = 3), sensory modulation rooms (N = 7), risk assessment and management protocols (N = 7), and comprehensive/mixed interventions (N = 22; N = 6 without empirical data). The relationship between the various protocols and outcomes was mixed. Psychiatric units that implement architecturally positive designs, sensory rooms, the Brøset Violence Checklist, and various multi-component comprehensive interventions may reduce seclusion events, though our certainty in these findings is low due to studies' methodological limitations. Future research and practice may benefit from standardised reporting of process and outcome measures and analyses that account for confounders.
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Affiliation(s)
- McKenzie Quinn
- Evidence Synthesis Program Center Providence VA Medical Center, Providence, Rhode Island, USA
| | - Eric Jutkowitz
- Evidence Synthesis Program Center Providence VA Medical Center, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Health Services, Policy & Practice, Brown University, Providence, Rhode Island, USA
| | - Jennifer Primack
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Psychiatry and Human Behavior, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Katherine Lenger
- Evidence Synthesis Program Center Providence VA Medical Center, Providence, Rhode Island, USA
| | - James Rudolph
- Evidence Synthesis Program Center Providence VA Medical Center, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
| | - Thomas Trikalinos
- Evidence Synthesis Program Center Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Health Services, Policy & Practice, Brown University, Providence, Rhode Island, USA
- Center for Evidence Synthesis in Health, Brown University, Providence, Rhode Island, USA
| | - Taylor Rickard
- Evidence Synthesis Program Center Providence VA Medical Center, Providence, Rhode Island, USA
| | - Htun Ja Mai
- Center for Evidence Synthesis in Health, Brown University, Providence, Rhode Island, USA
| | - Ethan Balk
- Evidence Synthesis Program Center Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Health Services, Policy & Practice, Brown University, Providence, Rhode Island, USA
- Center for Evidence Synthesis in Health, Brown University, Providence, Rhode Island, USA
| | - Kristin Konnyu
- Department of Health Services, Policy & Practice, Brown University, Providence, Rhode Island, USA
- Center for Evidence Synthesis in Health, Brown University, Providence, Rhode Island, USA
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
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Miodownik C, Friger MD, Teitelbaum A, Demchuk N, Zhuk A, Agababa T, Sokolik S, Lerner PP, Calfon N, Lerner V. Risk factors for coercion length at psychiatric hospitals in Israel: Relationship with staff. Indian J Psychiatry 2024; 66:36-42. [PMID: 38419935 PMCID: PMC10898533 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_814_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 06/27/2023] [Accepted: 11/11/2023] [Indexed: 03/02/2024] Open
Abstract
Background Coercive interventions continue to be applied frequently in psychiatric care when patients are at imminent risk of harming themselves and/or others. Aim The purpose of this study was to demonstrate the relationship between the length of coercion and a variety of factors, including the sociodemographic background of patients, their diagnoses and the characteristics of hospital staff. Methods This is a one-year cross-sectional retrospective study, including records of 298 patients who underwent restraint and/or seclusion interventions in male acute, closed wards in two psychiatric hospitals in Israel. Results A higher proportion of academic nurses to nonacademic nurses on duty leads to a shorter coercion time (P < 0.000). The number of male staff on duty, without any relation to their level of education, also leads to the shortening of the coercion time. Conclusion The presence of registered, academic female nurses, male staff on duty and the administration of medication before coercive measures can reduce the length of restriction.
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Affiliation(s)
- Chanoch Miodownik
- Be’er Sheva Mental Health Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Michael D. Friger
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | | | - Natalya Demchuk
- Be’er Sheva Mental Health Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | | | - Tsipora Agababa
- Be’er Sheva Mental Health Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Shmuel Sokolik
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | | | | | - Vladimir Lerner
- Be’er Sheva Mental Health Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
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Chavulak J, Smyth T, Sutcliffe N, Petrakis M. Staff Perspectives in Mental Health Research Regarding Restrictive Interventions: An Australian Scoping Review and Thematic Analysis. Behav Sci (Basel) 2023; 14:9. [PMID: 38247661 PMCID: PMC10812717 DOI: 10.3390/bs14010009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
Service users and their families have raised concerns about safety in current acute mental health service delivery. Restrictive interventions are routinely used across mental health settings despite increasing awareness of the negative impacts. Underfunding and risk-averse management practices are implicated as key challenges. Utilizing a scoping review and thematic analysis method, this review explored the existing literature of mental health staff perspectives across various settings (including psychiatric wards and emergency departments), focusing on their experience of restrictive interventions. Four themes were developed: 1. Safety (both staff and patient); 2. Barriers to staff reducing their restrictive interventions; 3. Strength in current practice; 4. Recommendations for change. Key gaps in the literature were the limited perspectives of emergency and crisis clinicians (despite these areas being settings where restrictive interventions are utilized) and limited perspectives from allied health disciplines (despite their employment as clinicians in these settings). It also noted a divide between staff and patient safety, as though these concerns are mutually exclusive rather than cooccurring, which is the experienced reality. Advocacy bodies, governments and the media are calling for a reduction in restrictive interventions in crisis settings. This research synthesis proposes that, to achieve this, clinical staff must be involved in the process and their perspectives actively sought and drawn upon to enable reform.
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Affiliation(s)
- Jacinta Chavulak
- Social Work Department, School of Primary and Allied Health Care, Caulfield Campus, Monash University, Caulfield East 3145, Australia;
- Mental Health Service, Alfred Health, Melbourne 3004, Australia; (T.S.); (N.S.)
| | - Terry Smyth
- Mental Health Service, Alfred Health, Melbourne 3004, Australia; (T.S.); (N.S.)
| | - Nicholas Sutcliffe
- Mental Health Service, Alfred Health, Melbourne 3004, Australia; (T.S.); (N.S.)
| | - Melissa Petrakis
- Social Work Department, School of Primary and Allied Health Care, Caulfield Campus, Monash University, Caulfield East 3145, Australia;
- Mental Health Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Australia
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Wasser T, Strockbine B, Uyanwune Y, Kapoor R. Restraint and Seclusion Practices and Policies in U.S. Forensic Psychiatric Hospitals. J Am Acad Psychiatry Law 2023; 51:566-574. [PMID: 38065618 DOI: 10.29158/jaapl.230099-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Over the last 30 years, there have been significant efforts to reduce the use of restraint and seclusion in psychiatric hospitals. Although authors have previously described restraint policies and practices in general psychiatry settings across the United States, this study is the first to attempt to describe policies regarding those practices in forensic hospital settings. We review the history of restraint and seclusion use in the United States, placing it within an international context. We then describe the results of a national survey of state forensic services directors regarding restraint modalities and policies in forensic hospital facilities. Twenty-nine respondents representing 25 states completed the survey. The results indicate that physical holds are the most frequently available method of restraint and that restraint chairs are the least frequently available. Most respondents reported having a policy regulating the use of restraint in their facilities, most commonly at the institutional level.
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Affiliation(s)
- Tobias Wasser
- Dr. Wasser is an Associate Professor of Psychiatry, Yale School of Medicine, New Haven, CT. Dr. Strockbine is the Chief Medical Officer, Whiting Forensic Hospital, Middletown, CT. Dr. Uyanwune is a Psychiatry Resident, Yale School of Medicine, New Haven, CT. Dr. Kapoor is an Associate Professor of Psychiatry, Yale School of Medicine, New Haven, CT.
| | - Bentley Strockbine
- Dr. Wasser is an Associate Professor of Psychiatry, Yale School of Medicine, New Haven, CT. Dr. Strockbine is the Chief Medical Officer, Whiting Forensic Hospital, Middletown, CT. Dr. Uyanwune is a Psychiatry Resident, Yale School of Medicine, New Haven, CT. Dr. Kapoor is an Associate Professor of Psychiatry, Yale School of Medicine, New Haven, CT
| | - Yvonne Uyanwune
- Dr. Wasser is an Associate Professor of Psychiatry, Yale School of Medicine, New Haven, CT. Dr. Strockbine is the Chief Medical Officer, Whiting Forensic Hospital, Middletown, CT. Dr. Uyanwune is a Psychiatry Resident, Yale School of Medicine, New Haven, CT. Dr. Kapoor is an Associate Professor of Psychiatry, Yale School of Medicine, New Haven, CT
| | - Reena Kapoor
- Dr. Wasser is an Associate Professor of Psychiatry, Yale School of Medicine, New Haven, CT. Dr. Strockbine is the Chief Medical Officer, Whiting Forensic Hospital, Middletown, CT. Dr. Uyanwune is a Psychiatry Resident, Yale School of Medicine, New Haven, CT. Dr. Kapoor is an Associate Professor of Psychiatry, Yale School of Medicine, New Haven, CT
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Bensemann C, Maxwell D, O'Keeffe K, Tresize L, Wairama K, Keelan W. Closing the equity gap as we move to the elimination of seclusion: Early results from a national quality improvement project. Australas Psychiatry 2023; 31:786-790. [PMID: 37772406 DOI: 10.1177/10398562231202125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
OBJECTIVE Use of seclusion within mental health inpatient facilities is harmful for consumers and staff, but it is still used in many Aotearoa New Zealand and Australian facilities, at higher, inequitable rates for the indigenous populations of both countries. We report early results from a national programme to eliminate seclusion in mental health services in Aotearoa New Zealand, using a bicultural approach to reduce inequity for Māori. METHOD The 'Zero Seclusion: Safety and dignity for all' programme, with programme teams nationwide, developed a co-designed bicultural change package combining Māori cultural and Western clinical interventions, incorporating quality improvement methodologies. Outcome measures included seclusion rates, duration, and average number of episodes per person admitted, by ethnicity, with a focus on equity. RESULTS Nationally, rates of seclusion for Māori reduced from the 12-month (to August 2019) baseline mean monthly rate of 7.5% to 6.8%, sustained from late 2020 to September 2022. The duration of seclusion for Māori reduced by 33% (4.5 h at baseline to 3.0). CONCLUSION A focus on inequity for Māori in use of seclusion, and a bicultural approach with cultural and clinical interventions, has been associated with a national reduction in rates and duration of seclusion for Māori.
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Affiliation(s)
- Clive Bensemann
- Mental Health and Addiction Quality Improvement Programme, New Zealand Health Quality and Safety Commission, Wellington, New Zealand
| | - Deirdre Maxwell
- Mental Health and Addiction Quality Improvement Programme, New Zealand Health Quality and Safety Commission, Wellington, New Zealand
| | - Karen O'Keeffe
- Mental Health and Addiction Quality Improvement Programme, New Zealand Health Quality and Safety Commission, Wellington, New Zealand
| | - Lee Tresize
- Health Quality Intelligence, New Zealand Health Quality and Safety Commission, Wellington, New Zealand
| | - Karl Wairama
- Mental Health and Addiction Quality Improvement Programme, New Zealand Health Quality and Safety Commission, Wellington, New Zealand
| | - Wikepa Keelan
- Mental Health and Addiction Quality Improvement Programme, New Zealand Health Quality and Safety Commission, Wellington, New Zealand
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Shetty SR, Burke S, Timmons D, Kennedy HG, Tuohy M, Terkildsen MD. Patient perspective on observation methods used in seclusion room in an Irish forensic mental health setting: A qualitative study. J Psychiatr Ment Health Nurs 2023. [PMID: 37929765 DOI: 10.1111/jpm.12979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 08/17/2023] [Accepted: 08/30/2023] [Indexed: 11/07/2023]
Abstract
WHAT IS KNOWN ON THE SUBJECT?: Nurses' observation of patients in seclusion is essential to ensure patient safety. Patient observation in seclusion assists nurses in adhering to the requirements of mental health legislation and hospital policy. Direct observation and video monitoring are widely used in observing patients in seclusion. Coercive practices may cause distress to patient-staff relations. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: We add detailed information on specific observation methods in seclusion and compare them from the perspective of patients. Nurses communicating with patients ensures relational contact and that quality care is provided to patients even in the most distressed phase of their illness. Providing prior information to patients on observation methods in seclusion and the need for engaging patients in meaningful activities, while in seclusion are emphasized. Observation via camera and nurses' presence near the seclusion room made patients feel safe and gave a sense of being cared for in seclusion. Pixellating the video camera would give a sense of privacy and dignity. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The overarching goal is to prevent seclusion. However, when seclusion is used as a last resort to manage risk to others, it should be done in ways that recognize the human rights of the patient, in ways that are least harmful, and in ways that recognize and cater to patients' unique needs. A consistent approach to relational contact and communication is essential. A care plan must include patient's preferred approach for interacting while in seclusion to support individualized care provision. Viewing panels (small window on the seclusion door) are important in establishing two-way communication with the patient. Educating nurses to utilize them correctly helps stimulate relational contact and communication during seclusion to benefit patients. Engaging patients in meaningful activities when in seclusion is essential to keep them connected to the outside world. Depending on the patient's presentation in the seclusion room and their preferences for interactions, reading newspapers, poems, stories, or a book chapter aloud to patients, via the viewing panel could help ensure such connectedness. More focus should be placed on providing communication training to nurses to strengthen their communication skills in caring for individuals in challenging care situations. Patient education is paramount. Providing prior information to patients using a co-produced information leaflet might reduce their anxiety and make them feel safe in the room. When using cameras in the seclusion room, these should be pixelated to maintain patients' privacy. ABSTRACT: Introduction A lack of research investigating the specific role that various observational techniques may have in shaping the therapeutic relations in mental health care during seclusion warranted this study. Aim The aim of the study was to explore patients' experience of different methods of observation used while the patient was in seclusion. Method A retrospective phenomenological approach, using semi-structured interviews, ten patients' experiences of being observed in the seclusion room was investigated. Colaizzi's descriptive phenomenological method was followed to analyse the data. Results Communicating and engaging patients in meaningful activities can be achieved via the viewing panel. The camera was considered essential in monitoring behaviour and promoting a sense of safety. Pixelating the camera may transform patient view on privacy in seclusion. Discussion The mental health services must strive to prevent seclusion and every effort should be made to recognise the human rights of the patient. The study reveals numerous advantages when nurses actively engage in patient communication during the process of observation. Implications for Practice Different observation methods yield different benefits; therefore, staff education in using these methods is paramount. Empowering the patient with prior information on seclusion, engaging them in meaningful activities and proper documentation on patient engagement, supports the provision of individualised care in seclusion.
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Affiliation(s)
- Shobha Rani Shetty
- National Forensic Mental Health Service, Central Mental Hospital, Dublin, Ireland
- School of Nursing Midwifery and Health Systems, University College Dublin (UCD), Dublin, Ireland
| | - Shauna Burke
- National Forensic Mental Health Service, Central Mental Hospital, Dublin, Ireland
| | - David Timmons
- National Forensic Mental Health Service, Central Mental Hospital, Dublin, Ireland
| | - Harry G Kennedy
- Forensic Psychiatry, Trinity College Dublin, Dublin, Ireland
- Forensic Psychiatry, Aarhus University, Dublin, Ireland
- Forensic Psychiatry, University of Bari 'Aldo Moro', Dublin, Ireland
| | - Mary Tuohy
- National Forensic Mental Health Service, Central Mental Hospital, Dublin, Ireland
| | - Morten Deleuran Terkildsen
- Department of Forensic Psychiatry, Centre for Forensic Psychiatric Research and Development (CerF), Aarhus University Hospital Psychiatry, Aarhus N, Denmark
- DEFACTUM, Central Denmark Region, Aarhus N, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus N, Denmark
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10
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Krückl JS, Moeller J, Imfeld L, Schädelin S, Hochstrasser L, Lieb R, Lang UE, Huber CG. The association between the admission to wards with open- vs. closed-door policy and the use of coercive measures. Front Psychiatry 2023; 14:1268727. [PMID: 37953938 PMCID: PMC10634515 DOI: 10.3389/fpsyt.2023.1268727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/09/2023] [Indexed: 11/14/2023] Open
Abstract
Introduction Psychiatric treatment on a ward with open-door policy is associated with reduced numbers of coercive measures. The effect of the door policy of previous stays, however, has not been investigated. Methods The data set consisted of 22,172 stays by adult inpatients in a psychiatric university hospital between 2010 and 2019. Pairs of consecutive stays were built. The outcome variable was the occurrence of coercive measures during the second stay. Results Compared to treatments on wards with a closed-door policy at both stays, treatments on wards with an open-door policy at the second stay had smaller odds for coercive measures (OR ranging between 0.09 and 0.33, p < 0.01). In addition, coercive measures were more frequent in treatment histories where patients previously treated on a closed ward were admitted to a ward with an open-door policy and subsequently transferred to a ward with a closed-door policy at the second stay (OR=2.97, p = 0.046). Discussion Treatment under open-door policy is associated with fewer coercive measures, even in patients with previous experience of closed-door settings. The group of patients who were admitted to a ward with an open-door, then transmitted to a ward with a closed-door policy seem to be prone to experience coercive measures. Clinical strategies to keep these patients in treatment in an open-door setting could further reduce coercive measures.
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Affiliation(s)
- Jana S. Krückl
- University Psychiatric Clinics Basel (UPK), University of Basel, Basel, Switzerland
- Division of Clinical Psychology and Epidemiology, Department of Psychology, University of Basel, Basel, Switzerland
| | - Julian Moeller
- University Psychiatric Clinics Basel (UPK), University of Basel, Basel, Switzerland
- Division of Clinical Psychology and Epidemiology, Department of Psychology, University of Basel, Basel, Switzerland
| | - Lukas Imfeld
- University Psychiatric Clinics Basel (UPK), University of Basel, Basel, Switzerland
| | - Sabine Schädelin
- Department Clinical Research, c/o University Hospital Basel, Basel, Switzerland
| | - Lisa Hochstrasser
- University Psychiatric Clinics Basel (UPK), University of Basel, Basel, Switzerland
| | - Roselind Lieb
- Division of Clinical Psychology and Epidemiology, Department of Psychology, University of Basel, Basel, Switzerland
| | - Undine E. Lang
- University Psychiatric Clinics Basel (UPK), University of Basel, Basel, Switzerland
| | - Christian G. Huber
- University Psychiatric Clinics Basel (UPK), University of Basel, Basel, Switzerland
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11
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van der Post LFM, Nusselder KJ, Peen J, Nabitz U, Dekker JM. Effect of coercive measures on treatment outcome in involuntarily admitted patients in Amsterdam. Front Psychiatry 2023; 14:1240129. [PMID: 37810601 PMCID: PMC10556454 DOI: 10.3389/fpsyt.2023.1240129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/04/2023] [Indexed: 10/10/2023] Open
Abstract
Objective The prevalence of involuntary admissions rose the last forty years in European countries, including the Netherlands. Involuntary admissions result in seclusion, physical restraint and forced medication in approximately 40% of patients. We looked at whether treatment outcomes differ in patients with and without coercive measures. Methods Using The Health of the Nation Outcome Scales (HoNOS) to measure treatment outcomes, we studied the files of 786 patients admitted involuntarily to an Amsterdam clinic. We applied Generalised Linear Models to determine whether the use, or not, of coercive measures during treatment was associated with a difference in outcomes. Results 19% of the cohort were secluded in a High Security Room (HSR); 24% were secluded in their own room and/or received forced medication. After adjustment for the influence of diagnosis, disorder severity (initial HoNOS score) and treatment duration, the HSR group had, on average, a HoNOS difference score that was 2.4 points lower than patients without coercive measures (CI -4.0 to -0.8.; p 0.003). In the seclusion in own room group, this score was 2.6 points lower (CI -4.0 to -1.1; p 0.001), corresponding to an effect size of 0.35 and 0.40, respectively. Conclusion Seclusion, whether or not in combination with forced medication, was applied to two-fifths of patients. The HoNOS scores of the group without coercion improved by nearly two and a half points more on average than those of the two groups with coercion. A causal relationship between coercion and treatment outcome could neither be confirmed nor excluded on the basis of our results.
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Affiliation(s)
| | - K. J. Nusselder
- Research Department, ARKIN Mental Health Care, Amsterdam, Netherlands
| | - J. Peen
- Research Department, ARKIN Mental Health Care, Amsterdam, Netherlands
| | - U. Nabitz
- Research Department, ARKIN Mental Health Care, Amsterdam, Netherlands
| | - J. M. Dekker
- Research Department, ARKIN Mental Health Care, Amsterdam, Netherlands
- Department of Psychology, Faculty of Psychology and Pedagogy, Vrije Universiteit, Amsterdam, Netherlands
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12
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Abstract
OBJECTIVES Restrictive interventions (seclusion, restraint and special observations) are used on psychiatric wards when there are no other means available to keep a patient or others safe. These measures can be traumatic, and the Mental Health Commission and the Health Service Executive are focused on minimising their use. We set out to determine whether, following a COVID related reduction in bed numbers on a high dependency psychiatric ward in St John of God Hospital in Dublin, there was a change in their incidence. METHODS Data on restrictive interventions and challenging behaviours were gathered for 9-month periods before and after March 2020 when COVID related ward changes took place. Figures were also collected on seclusion and restraint for the previous 18 months for a longer-term view. Ward and hospital occupancy levels were also recorded. RESULTS Between the two time periods, episodes of seclusion fell by 53% and episodes of restraint by 56%. The hours devoted to special observation declined by 30% and incidents of challenging behaviours fell by 26%. Ward occupancy levels fell by only 5%. The longer-term comparison of figures for seclusion and restraint point towards a downward trend from mid-2019 that was accentuated in the post-COVID period. CONCLUSIONS The changes found may relate to reduced crowding on the ward or other COVID related factors such as the emphasis on social distancing and a shared sense of purpose on the ward. The longer-term trend points towards an emerging cultural shift. The challenge now is to sustain and build upon these changes.
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Affiliation(s)
- L Feeney
- Cluain Mhuire Community Services, Newtownpark Avenue, Blackrock, Co., Dublin, Dublin, Ireland
| | - N Bonner
- Department of Nursing, St. John of God Hospital, Stillorgan, Co., Dublin, Dublin, Ireland
| | - J McAndrew
- Cluain Mhuire Community Services, Newtownpark Avenue, Blackrock, Co., Dublin, Dublin, Ireland
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13
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McDonnell AA, O’Shea MC, Bews-Pugh SJ, McAulliffe H, Deveau R. Staff training in physical interventions: a literature review. Front Psychiatry 2023; 14:1129039. [PMID: 37564241 PMCID: PMC10411725 DOI: 10.3389/fpsyt.2023.1129039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/30/2023] [Indexed: 08/12/2023] Open
Abstract
Background Restrictive practices are used frequently by frontline staff in a variety of care contexts, including psychiatric hospitals, children's services, and support services for older adults and individuals with intellectual and developmental disabilities. Physical restraint has been associated with emotional harm, physical injury to staff and consumers, and has even resulted in death of individuals in care environments. Various interventions have been implemented within care settings with the intention of reducing instances of restraint. One of the most common interventions is staff training that includes some physical intervention skills to support staff to manage crisis situations. Despite physical intervention training being used widely in care services, there is little evidence to support the effectiveness and application of physical interventions. This review will examine the literature regarding outcomes of staff training in physical interventions across care sectors. Method A systematic search was conducted following PRISMA guidelines using Cochrane Database, Medline EBSCO, Medline OVID, PsychINFO, and the Web of Science. Main search keywords were staff training, physical intervention, physical restraint. The MMAT was utilised to provide an analytical framework for the included studies. Results and discussion Seventeen articles have been included in this literature review. The included studies take place in a range of care settings and comprise a wide range of outcomes and designs. The training programmes examined vary widely in their duration, course content, teaching methods, and extent to which physical skills are taught. Studies were of relatively poor quality. Many descriptions of training programmes did not clearly operationalise the knowledge and skills taught to staff. As such, it is difficult to compare course content across the studies. Few papers described physical interventions in sufficient detail. This review demonstrates that, although staff training is a 'first response' to managing health and safety in care settings, there is very little evidence to suggest that staff training in physical intervention skills leads to meaningful outcomes.
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Affiliation(s)
| | | | | | | | - Roy Deveau
- Tizard Centre, University of Kent, Canterbury, United Kingdom
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14
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Perkins E, Blair EW, Allen DE, Teal LA, Marcus PE, Fordmeir JL. Updates to American Psychiatric Nurses Association: Seclusion and Restraint Position Statement and Standards of Practice. J Am Psychiatr Nurses Assoc 2023:10783903231184200. [PMID: 37382297 DOI: 10.1177/10783903231184200] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
OBJECTIVE The purpose of this discussion paper is to summarize the 2022 updates to the American Psychiatric Nurses Association's (APNA) Seclusion and Restraint Position Statement and Seclusion and Restraint Standards of Practice. METHOD Both documents were the work of the APNA 2022 Seclusion and Restraint Task Force that consisted of APNA nurses with expertise in the use of Seclusion and Restraint, who practice across a wide range of clinical settings. RESULTS The 2022 Updates to the APNA Position Statement and Standards were guided by evidence-based information found in the review of seclusion and restraint literature and clinical expertise from the 2022 Seclusion and Restraint Task Force. CONCLUSIONS Updates were evidence-based and in line with APNA's core values and initiatives in diversity, equity, and inclusion.
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Affiliation(s)
- Evelyn Perkins
- Evelyn Perkins, MS, RN, PMH-BC, NE-BC, American Psychiatric Nurses Association, Falls Church, VA, USA
- Evelyn Perkins, MS, RN, PMH-BC, NE-BC, Northwestern Memorial Hospital, Olympia Fields, IL, USA
| | - Ellen W Blair
- Ellen W. Blair, DNP, APRN, PMHCNS-BC, NEA-BC, CPHQ, FAAN, Hartford HealthCare, Hartford, CT, USA
| | - Diane E Allen
- Diane E. Allen, DNP, PMHRN-BC, FACHE(R), Private Practice, Manchester NH USA
| | - Lincoln Akre Teal
- Lincoln Akre Teal, RN, MSN, PMH-BC, Boston Children's Hospital, Boston, MA, USA
- Lincoln Akre Teal, Salem State University, Salem, MA, USA
| | - Pamela E Marcus
- Pamela E. Marcus, RN APRN/PMH-BC, Prince George's Community College, Largo, MD, USA
| | - Jennifer L Fordmeir
- Jennifer L. Fordmeir, MSN, ARNP, PMHNP-BC, ARNP, Mindful Psychiatry, Kennewick, WA USA
- Jennifer L. Fordmeir, MSN, ARNP, PMHNP-BC, ARNP, Awareness Consulting & Training, Kennewick, WA, USA
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15
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Nikopaschos F, Burrell G, Clark J, Salgueiro A. Trauma-Informed Care on mental health wards: the impact of Power Threat Meaning Framework Team Formulation and Psychological Stabilisation on self-harm and restrictive interventions. Front Psychol 2023; 14:1145100. [PMID: 37359880 PMCID: PMC10285464 DOI: 10.3389/fpsyg.2023.1145100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 04/10/2023] [Indexed: 06/28/2023] Open
Abstract
Aim The aim of this evaluation was to assess the impact of introducing a model of Trauma-Informed Care (TIC), comprising weekly Power Threat Meaning Framework (PTMF) Team Formulation and weekly Psychological Stabilisation staff training, to a National Health Service (NHS) adult acute inpatient mental health unit over a four-year period. Method A retrospective service evaluation design was employed to assess for differences in the number of incidents of self-harm, seclusion and restraint in the four-year period following the introduction of TIC, when compared to the year prior. Results Significant reductions were demonstrated in the monthly number of incidents of self-harm (p < 0.01; r = 0.42), seclusion (p < 0.05; r = 0.30) and restraint (p < 0.05; d = 0.55) following the introduction of TIC. Conclusion Findings suggest that PTMF Team Formulation and Psychological Stabilisation training can contribute to significant reductions in self-harm and restrictive interventions (seclusion and restraint) on adult mental health wards. Qualitative interviews with staff and service users from the unit will support a better understanding of the mechanisms of this change. Further research, employing a randomised control trial design, could increase the validity and generalisability of findings. However, the ethical implications of withholding potentially beneficial practices from a control group would need to be considered.
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16
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Lacambre M, Péchillon É, Fovet T. [Isolation and mechanical restraint in psychiatry]. Rev Infirm 2023; 72:16-19. [PMID: 37364969 DOI: 10.1016/j.revinf.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
Since 2016, there has been a succession of legal texts aimed at framing the use of seclusion and mechanical restraint in psychiatric services. These legal evolutions are not without consequence on the practice of caregivers. We propose here a practical summary of this issue.
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Affiliation(s)
- Mathieu Lacambre
- Unité de soins intensifs de psychiatrie, Filière de psychiatrie légale, CHU Montpellier, 191 avenue du Doyen-Gaston-Giraud, 34295 Montpellier, cedex 5, France; Section psychiatrie légale, Association française de psychiatrie biologique et de neuropsychopharmacologie (AFPBN), Centre hospitalier Sainte-Anne, 1 rue Cabanis, 75674 Paris, France.
| | - Éric Péchillon
- Faculté DSEG de Vannes, Lab-LEX/UR 7480, Université Bretagne Sud, rue André-Lwoff, 56000 Vannes, France
| | - Thomas Fovet
- Section psychiatrie légale, Association française de psychiatrie biologique et de neuropsychopharmacologie (AFPBN), Centre hospitalier Sainte-Anne, 1 rue Cabanis, 75674 Paris, France; University Lille, Inserm, CHU Lille, U1172-Lille Neuroscience & Cognition, 59000 Lille, France
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17
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Hirsch S, Baumgardt J, Bechdolf A, Bühling-Schindowski F, Cole C, Flammer E, Mahler L, Muche R, Sauter D, Vandamme A, Steinert T. Implementation of guidelines on prevention of coercion and violence: baseline data of the randomized controlled PreVCo study. Front Psychiatry 2023; 14:1130727. [PMID: 37252153 PMCID: PMC10213907 DOI: 10.3389/fpsyt.2023.1130727] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/17/2023] [Indexed: 05/31/2023] Open
Abstract
Introduction The PreVCo study examines whether a structured, operationalized implementation of guidelines to prevent coercion actually leads to fewer coercive measures on psychiatric wards. It is known from the literature that rates of coercive measures differ greatly between hospitals within a country. Studies on that topic also showed large Hawthorne effects. Therefore, it is important to collect valid baseline data for the comparison of similar wards and controlling for observer effects. Methods Fifty five psychiatric wards in Germany treating voluntary and involuntary patients were randomly allocated to an intervention or a waiting list condition in matched pairs. As part of the randomized controlled trial, they completed a baseline survey. We collected data on admissions, occupied beds, involuntarily admitted cases, main diagnoses, the number and duration of coercive measures, assaults and staffing levels. We applied the PreVCo Rating Tool for each ward. The PreVCo Rating Tool is a fidelity rating, measuring the degree of implementation of 12 guideline-linked recommendations on Likert scales with a range of 0-135 points covering the main elements of the guidelines. Aggregated data on the ward level is provided, with no patient data provided. We performed a Wilcoxon signed-rank-test to compare intervention group and waiting list control group at baseline and to assess the success of randomization. Results The participating wards had an average of 19.9% involuntarily admitted cases and a median 19 coercive measures per month (1 coercive measure per occupied bed, 0.5 per admission). The intervention group and waiting list group were not significantly different in these measurements. There were 6.0 assaults per month on average (0.3 assaults per occupied bed and 0.1 per admission). The PreVCo Rating Tool for guideline fidelity varied between 28 and 106 points. The percentage of involuntarily admitted cases showed a correlation with coercive measures per month and bed (Spearman's Rho = 0.56, p < 0.01). Discussion Our findings that coercion varies widely within a country and mainly is associated with involuntarily admitted and aggressive patients are in line with the international literature. We believe that we included a sample that covers the scope of mental health care practice in Germany well.Clinical trial registration: www.isrctn.com, identifier ISRCTN71467851.
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Affiliation(s)
- Sophie Hirsch
- Department for Psychiatry and Psychotherapy I, Faculty of Medicine, Ulm University, Ulm, Germany
- Department for Psychiatry and Psychotherapy Biberach, ZfP Südwürttemberg, Biberach, Germany
| | - Johanna Baumgardt
- Department of Psychiatry, Psychotherapy and Psychosomatics, Vivantes Hospital Am Urban, Berlin, Germany
- Research Institute of the Local Health Care Funds (WIdO), Berlin, Germany
| | - Andreas Bechdolf
- Department of Psychiatry, Psychotherapy and Psychosomatics, Vivantes Hospital Am Urban, Berlin, Germany
- Department of Psychiatry and Psychotherapy, Charité Univesitätsmedizin, Berlin, Germany
| | - Felix Bühling-Schindowski
- Department of Psychiatry, Psychotherapy and Psychosomatics, Vivantes Hospital Am Urban, Berlin, Germany
| | - Celline Cole
- Department of Psychiatry and Psychotherapy, Charité Univesitätsmedizin, Berlin, Germany
| | - Erich Flammer
- Department for Psychiatry and Psychotherapy I, Faculty of Medicine, Ulm University, Ulm, Germany
| | - Lieselotte Mahler
- Department of Psychiatry and Psychotherapy, Charité Univesitätsmedizin, Berlin, Germany
- Department of Psychiatry and Psychotherapy, Clinics in the Theodor-Wenzel-Werk, Berlin, Germany
| | - Rainer Muche
- Faculty of Medicine, Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Dorothea Sauter
- Department for Psychiatry and Psychotherapy I, Faculty of Medicine, Ulm University, Ulm, Germany
| | - Angelika Vandamme
- Department of Psychiatry and Psychotherapy, Charité Univesitätsmedizin, Berlin, Germany
| | | | - Tilman Steinert
- Department for Psychiatry and Psychotherapy I, Faculty of Medicine, Ulm University, Ulm, Germany
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18
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Nagayama Y, Tanaka K, Oe M. Strengths Model-Based Nursing Interventions for Inpatients in Psychiatric Inpatient Settings Using a Seclusion Room: A Case Series Study. Nurs Rep 2023; 13:644-658. [PMID: 37092485 PMCID: PMC10123628 DOI: 10.3390/nursrep13020057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 04/25/2023] Open
Abstract
The use of coercive measures in psychiatric inpatient settings has been an important issue for many years. Nursing interventions based on a strengths model could enable a reduction in the use of these measures. This study aimed to describe the practice of nursing interventions using a strengths model for psychiatric inpatients who have been in seclusion for a long time. We also constructed a nursing model to minimize coercive measures. The participants were eight inpatients who had been in seclusion for a long time. Nursing interventions based on a strengths model were implemented in collaboration with nurses from six long-term care units in three psychiatric hospitals in Japan. For 4 of the 8 participants, the seclusion time decreased by 20-45%. However, for another 2, it increased by about 23-34%. An average decrease of 9.6% was observed, and the open observation time increased by 1.4 h per day on the seclusion days. When using this model, the nurses considered the effects of stimulating strengths. We believe this approach may promote inpatients' self-insight. Considering the perspective of stimulus adjustment might be useful for maximizing the positive effects of working on strengths.
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Affiliation(s)
- Yutaka Nagayama
- School of Nursing, Kanazawa Medical University, 1-1 Uchinada, Kahoku 920-0265, Japan
| | - Koji Tanaka
- Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa 920-0942, Japan
| | - Masato Oe
- School of Nursing, Kanazawa Medical University, 1-1 Uchinada, Kahoku 920-0265, Japan
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19
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Yurtbasi MK, Melvin G, Pavlou C, Gordon M. Staff perspectives on the effects of seclusion in adolescent psychiatric inpatient care. Int J Ment Health Nurs 2023; 32:567-578. [PMID: 36524302 DOI: 10.1111/inm.13102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 12/23/2022]
Abstract
Nurses are at the forefront of seclusion in adolescent psychiatric units. Understanding nurses and other staff perspectives on the effects of seclusion is critical in the ongoing effort to minimize and eliminate seclusion. The aim of this study was to gain a better understanding of staff attitudes, experiences, and beliefs about the effects of seclusion on both themselves and patients. Thirty-one staff members (including 20 nurses) completed the Attitudes to Seclusion Survey and 24 participated in semi-structured interviews to explore their beliefs and experiences of seclusion use in adolescent psychiatric inpatient care. Analysis of the questionnaire showed overwhelming agreement in the negative impacts of seclusion on patients, while there was uncertainty around the positive impacts of seclusion. Using a combination of the intuitive approach and thematic analysis, five themes were identified from interviews with staff, three unique to nurses: (i) staff were reluctant to use seclusion but felt it was necessary, (ii) nurses felt under-resourcing led to increased chances of seclusion, (iii) staff believed seclusion negatively impacted the patients, (iv) nurses felt their relationships with patients were negatively impacted, and (v) seclusion also had a negative effect on nurses. Clinical recommendations included a systematic and structured approach to debriefing to repair ruptures in the therapeutic relationship; staffing to be based on the acuity of the unit rather than occupancy; alternatives to seclusion that meet the needs of service providers and consumers. Future research should compare staff and patient perspectives, include multiple sites, and greater participation of non-nursing staff.
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Affiliation(s)
- Miriam K Yurtbasi
- Centre for Developmental Psychiatry and Psychology, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Glenn Melvin
- School of Psychology, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Christine Pavlou
- Early in Life Mental Health Service, Monash Children's Hospital, Clayton, Victoria, Australia
| | - Michael Gordon
- Centre for Developmental Psychiatry and Psychology, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia.,Early in Life Mental Health Service, Monash Children's Hospital, Clayton, Victoria, Australia
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20
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O'Callaghan AK, Plunkett R, Kelly BD. What is the role of gender in perceived coercion during psychiatric admission? Ir J Psychol Med 2023:1-5. [PMID: 36803581 DOI: 10.1017/ipm.2023.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
OBJECTIVES This paper explores factors linking gender with increased perceived coercion, perceived negative pressures and procedural injustice during psychiatric admission. METHODS We used validated tools to perform detailed assessments of 107 adult psychiatry inpatients admitted to acute psychiatry admission units at two general hospitals in Dublin, Ireland, between September 2017 and February 2020. RESULTS Among female inpatients (n = 48), perceived coercion on admission was associated with younger age and involuntary status; perceived negative pressures were associated with younger age, involuntary status, seclusion, and positive symptoms of schizophrenia; and procedural injustice was associated with younger age, involuntary status, fewer negative symptoms of schizophrenia, and cognitive impairment. Among females, restraint was not associated with perceived coercion on admission, perceived negative pressures, procedural injustice, or negative affective reactions to hospitalisation; seclusion was associated with negative pressures only. Among male inpatients (n = 59), not being born in Ireland appeared more relevant than age, and neither restraint nor seclusion were associated with perceived coercion on admission, perceived negative pressures, procedural injustice, or negative affective reactions to hospitalisation. CONCLUSIONS Factors other than formal coercive practices are primarily linked with perceived coercion. Among female inpatients, these include younger age, involuntary status, and positive symptoms. Among males, not being born in Ireland appears more relevant than age. Further research is needed on these correlations, along with gender-aware interventions to minimise coercive practices and their consequences among all patients.
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Affiliation(s)
- Aoife K O'Callaghan
- Department of Psychiatry, Trinity Centre for Health Sciences, Tallaght University Hospital, Tallaght, Dublin 24, D24 NR0A, Ireland
| | - Róisín Plunkett
- Psychological Medicine Department, St James's Hospital, Dublin 8, Ireland
| | - Brendan D Kelly
- Department of Psychiatry, Trinity Centre for Health Sciences, Tallaght University Hospital, Tallaght, Dublin 24, D24 NR0A, Ireland
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21
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Galbert I, Azab AN, Kaplan Z, Nusbaum L. Staff attitudes and perceptions towards the use of coercive measures in psychiatric patients. Int J Ment Health Nurs 2023; 32:106-116. [PMID: 36070221 DOI: 10.1111/inm.13064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2022] [Indexed: 01/14/2023]
Abstract
The failure of efforts to significantly reduce the use of physical coercive measures (PCMs) in psychiatric hospitals remains a global concern. There is a gap in the understanding of staff's characteristics that may affect their attitudes and perceptions towards PCMs. This study used a cross-sectional design to examine the attitudes and perceptions of staff working at a mental health centre in Israel regarding the use of PCMs and to explore whether staff attitudes differed depending on their professional and demographic background. This study also sought to explore staff willingness to accept a policy of reducing the use of PCMs. The data were collected from 149 staff members (nurses, physicians, and auxiliary staff) working at mental health centre, using a questionnaire developed for this study. The findings indicate a low degree of support for use of PCMs among participants who were older, female, more qualified psychiatric nurses, with longer duration of employment, and those who have not participated in coercive intervention in the past year. The majority of the sample reported a low willingness to reduce the use of PCMs, and a lack of institutional support after participating in a coercive event. High hospital occupancy and insufficient staffing were perceived as contributing factors to coercive incidents. Therefore, availability of trained and experienced staff, elimination of organizational barriers, along with creating and maintaining a safe clinical environment should be a priority. Alternative non-coercive interventions should further be taught and used for managing aggressive and violent behaviour in the psychiatric clinical settings.
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Affiliation(s)
- Ilya Galbert
- Department of Nursing, Recanati School of Community Health Professions, Ben-Gurion University of the Negev Faculty of Health Sciences, Beer-Sheva, Israel
| | - Abed N Azab
- Department of Nursing, Recanati School of Community Health Professions, Ben-Gurion University of the Negev Faculty of Health Sciences, Beer-Sheva, Israel.,Department of Clinical Biochemistry and Pharmacology, Ben-Gurion University of the Negev Faculty of Health Sciences, Beer-Sheva, Israel
| | - Zeev Kaplan
- Beer-Sheva Mental Health Center, Beer-Sheva, Israel.,Ben-Gurion University of the Negev Faculty of Health Sciences, Beer-Sheva, Israel
| | - Lika Nusbaum
- Department of Nursing, Recanati School of Community Health Professions, Ben-Gurion University of the Negev Faculty of Health Sciences, Beer-Sheva, Israel
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22
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Berg J, Lipponen E, Sailas E, Soininen P, Varpula J, Välimäki M, Lahti M. Nurses' perceptions of nurse-patient communication in seclusion rooms in psychiatric inpatient care: A focus group study. J Psychiatr Ment Health Nurs 2023. [PMID: 36718606 DOI: 10.1111/jpm.12907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 12/16/2022] [Accepted: 01/18/2023] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Communication between nurses and patients is essential in mental health nursing. In coercive situations (e.g. seclusion), the importance of nurse-patient communication is highlighted. However, research related to nurses' perceptions of nurse-patient communication during seclusion is scant. AIM The aim of this study was to describe nurses' perceptions of nurse-patient communication during patient seclusion and the ways nurse-patient communication can be improved. METHOD A qualitative study design using focus group interviews was adopted. Thirty-two nurses working in psychiatric wards were recruited to participate. The data were analysed using inductive qualitative content analysis. RESULTS Nurses aimed to communicate in a patient-centred way in seclusion events, and various issues affected the quality of communication. Nurses recognized several ways to improve communication during seclusion. DISCUSSION Treating patients in seclusion rooms presents highly demanding care situations for nurses. Seclusion events require nurses to have good communication skills to provide ethically sound care. CONCLUSION Improved nurse-patient communication may contribute to shorter seclusion times and a higher quality of care. Improving nurses' communication skills may help support the dignity of the secluded patients. Safewards practices, such as respectful communication and recognizing the effect of non-verbal behaviour, could be considered when developing nurse-patient communication in seclusion events. RELEVANCE STATEMENT This study deepens the understanding of nurse-patient communication during seclusion events from the perspective of nurses. Caring for patients in seclusion presents challenging situations for nurses and demands that they have good communication skills. To enhance their communication skills in seclusion events, nurses require opportunities to take part in further training after education related to communication skills for demanding care situations. Knowing the appropriate ways to interact with individual patients during seclusion can help nurses create and maintain communication with patients. For mental health nursing, nurses' enhanced communication may promote increased use of noncoercive practices in psychiatric settings. For patients, improving nurses' communication skills may help support dignity and autonomy during seclusion and shorten the time spent in seclusion, resulting in a better quality of care and more positive patient experiences related to care offered in seclusion. In this, the perspectives of people with lived experience of mental health problems should be acknowledged. Components of Safewards practices, such as using respectful and individual communication and paying attention to one's non-verbal communication (Soft Words), could be useful when developing nurse-patient communication in seclusion events.
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Affiliation(s)
- Johanna Berg
- Turku University of Applied Sciences, Turku, Finland
| | | | - Eila Sailas
- Helsinki University Hospital, Kellokoski Hospital, Kellokoski, Finland
| | - Päivi Soininen
- Helsinki University Hospital, Kellokoski Hospital, Kellokoski, Finland.,Department of Nursing Science, University of Turku, Turku, Finland
| | - Jaakko Varpula
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Maritta Välimäki
- Department of Nursing Science, University of Turku, Turku, Finland.,Xiangya Nursing School, Central South University, Changsha, China
| | - Mari Lahti
- Turku University of Applied Sciences, Turku, Finland.,Department of Nursing Science, University of Turku, Turku, Finland
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23
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Müller M, Brackmann N, Jäger M, Theodoridou A, Vetter S, Seifritz E, Hotzy F. Predicting coercion during the course of psychiatric hospitalizations. Eur Psychiatry 2023; 66:e22. [PMID: 36700423 PMCID: PMC9981454 DOI: 10.1192/j.eurpsy.2023.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Coercive measures (such as seclusion, mechanical restraint, and forced medication) during psychiatric inpatient treatment should be avoided whenever possible. Different interventions were already developed to reduce coercion, but for their effective application, it is crucial to know the risk factors of individuals and clinical situations that might be associated with coercion. Since the results of previous studies differ considerably the current study aims to fill this gap by evaluating the course of the exertion of coercion in detail. METHODS In this study, we analyzed clinical, procedural, and sociodemographic data from patients (n = 16,607 cases) who were treated as inpatients in Switzerland's largest psychiatric institution with 320 beds during the years 2017 to 2020. We used regression models to identify predictors for the exertion of coercion, the number of coercive measures during a treatment episode and time until exertion of the first and last coercive measure. RESULTS Coercive measures are mostly used during the first days of treatment. We identified clinical parameters such as manic or psychotic episodes to be the most relevant predictors for the exertion of coercion. Cases with those disorders also received coercion more often and earlier in their treatment course than other diagnostic groups. Other promoting factors for frequency and early application of coercion were involuntary admission and factors of chronicity and clinical severity. CONCLUSIONS Knowing the risk factors may help to target preventive strategies for those at highest risk. In particular, interventions should focus on the critical timeframe at the beginning of treatment.
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Affiliation(s)
- Mario Müller
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Zürich, Switzerland
| | - Nathalie Brackmann
- Department of Forensic Psychiatry, Psychiatric University Hospital Zurich, University of Zurich, Zürich, Switzerland
| | - Matthias Jäger
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Zürich, Switzerland
| | - Anastasia Theodoridou
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Zürich, Switzerland
| | - Stefan Vetter
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Zürich, Switzerland
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Zürich, Switzerland
| | - Florian Hotzy
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Zürich, Switzerland
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24
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Billé V, Gonsalvès C. [The care partnership pact in adult psychiatry]. Soins 2023; 68:54-8. [PMID: 36894232 DOI: 10.1016/j.soin.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Programs to reduce the use of coercive measures emphasize the importance of patient involvement in their care and the use of formalized tools. An adult psychiatric care admission unit offers a specific tool to the hospitalized patient: the "Preventive Emotion Management Questionnaire", as soon as the patient is admitted to the unit. Thus, in case of a crisis period, caregivers will know what the patient's wishes are, which will facilitate the implementation of a care partnership, guided by two nursing theories.
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25
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Faerden A, Rosenqvist C, Håkansson M, Strøm-Gundersen E, Stav Å, Svartsund J, Røssæg T, Davik N, Kvarstein E, Pedersen G, Dieset I, Nyrud AQ, Weedon-Fekjær H, Kistorp KM. Environmental Transformations Enhancing Dignity in an Acute Psychiatric Ward: Outcome of a User-Driven Service Design Project. HERD 2022; 16:55-72. [PMID: 36567605 PMCID: PMC10133780 DOI: 10.1177/19375867221136558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The goal of the current project was to enhance the feeling of dignity for patients in the seclusion unit in an acute psychiatric ward through environmental design changes and to evaluate the effect of the refurbishment. BACKGROUND Treating people with dignity is essential in all health-related work and important for our mental health. Hospital architecture and design signal values that can promote dignity. Patients who must spend time in seclusion are at their most vulnerable mental state and the often worn-down like environment can challenge the feeling of dignity. How environmental design can promote dignity in seclusion units have not been studied. METHODS To reach suggestions for design changes enhancing dignity, we used service design that included a broad user group. The effect of design changes was evaluated by a questionnaire answered by the nursing staff during a 4-week period pre- and post refurbishment and included a control group. RESULTS The design concepts agreed upon were a welcoming atmosphere, contact with nature, room for privacy, close contact with staff, and a designated smoking area inside the unit. The evaluation found that the environmental design changes significantly supported the patients in their situation and the staff in their work. CONCLUSION We conclude that dignity design concepts are highly applicable also in an acute psychiatric setting and improve the situation of secluded mental health patients, which is much needed. Findings align with other environmental changes in psychiatric wards that improve the patients' well-being and reduce aggression.
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Affiliation(s)
- Ann Faerden
- Department of Acute Psychiatry, Oslo University Hospital, Norway
| | - Christine Rosenqvist
- User Representative Advisory Board, Department of Acute Psychiatry, Oslo University Hospital, Norway
| | | | | | | | | | - Trude Røssæg
- Department of Acute Psychiatry, Oslo University Hospital, Norway
| | - Nils Davik
- Department of Acute Psychiatry, Oslo University Hospital, Norway
| | - Elfrida Kvarstein
- Section for Personality Psychiatry and Specialized Treatment, Oslo University Hospital, Norway
| | - Geir Pedersen
- Section for Personality Psychiatry and Specialized Treatment, Oslo University Hospital, Norway
| | - Ingrid Dieset
- Department of Acute Psychiatry, Oslo University Hospital, Norway
| | | | - Harald Weedon-Fekjær
- Oslo Center for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Norway
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26
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De Cuyper K, Vanlinthout E, Vanhoof J, van Achterberg T, Opgenhaffen T, Nijs S, Peeters T, Put J, Maes B, Van Audenhove C. Best practice recommendations on the application of seclusion and restraint in mental health services: An evidence, human rights and consensus-based approach. J Psychiatr Ment Health Nurs 2022; 30:580-593. [PMID: 36565433 DOI: 10.1111/jpm.12890] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/27/2022] [Accepted: 12/13/2022] [Indexed: 12/25/2022]
Abstract
UNLABELLED WHAT IS KNOWN ON THE SUBJECT?: Seclusion and restraint still regularly occur within inpatient mental health services. The Council of Europe requires the development of a policy on for instance age limits, techniques and time limits. However, they only define the outer limits of such a policy by indicating when rights are violated. Within these limits, many choices remain open. Staff and service managers lack clarity on safe and humane procedures. Research literature provides limited and contradictory insights on these matters. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The study resulted in 77 best practice recommendations on the practical application of restraint and seclusion as last resort intervention in inpatient youth and adult mental health services, including forensic facilities. To our knowledge, this is the first study in which the development of recommendations on this topic is not only based on scientific evidence, but also on an analysis of European human rights standards and consensus within and between expert-professionals and experts-by-experience. This approach allowed to develop for the first time recommendations on time limits, asking for second opinion, and registration of seclusion and restraint. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The 77 recommendations encourage staff to focus on teamwork, safety measures, humane treatment, age and time limits, asking for second opinion, observation, evaluation and registration when applying seclusion and restraint as last resort intervention. The implementation of the best practice recommendations is feasible provided that they are combined with a broad preventive approach and with collaboration between service managers, staff (educators) and experts-by-experience. Under these conditions, the recommendations will improve safety and humane treatment, and reduce harm to both service users and staff. ABSTRACT INTRODUCTION: Seclusion and restraint still regularly occur within inpatient mental health services. Professionals lack clarity on safe and humane procedures. Nevertheless, a detailed policy on for instance age limits, techniques and time limits is required. AIM We developed recommendations on the humane and safe application of seclusion, physical intervention and mechanical restraint in inpatient youth and adult mental health services, including forensic facilities. METHOD After developing a questionnaire based on a rapid scientific literature review and an analysis of human rights sources stemming from the Council of Europe, 60 expert-professionals and 18 experts-by-experience were consulted in Flanders (Belgium) through a Delphi-study. RESULTS After two rounds, all but one statement reached the consensus-level of 65% in both panels. The study resulted in 77 recommendations on teamwork, communication, materials and techniques, maximum duration, observation, evaluation, registration, second opinion and age limits. DISCUSSION Combining an evidence, human rights and consensus-based approach allowed for the first time to develop recommendations on time limits, asking for second opinion and registration. IMPLICATIONS FOR PRACTICE When combined with a preventive approach and collaboration between service managers, staff (educators) and experts-by-experience, the recommendations will improve safety and humane treatment, and reduce harm to service users and staff.
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Affiliation(s)
- Kathleen De Cuyper
- LUCAS - Centre for Care Research & Consultancy, University of Leuven, Leuven, Belgium
| | - Els Vanlinthout
- LUCAS - Centre for Care Research & Consultancy, University of Leuven, Leuven, Belgium
| | - Jasper Vanhoof
- Academic Centre of Nursing and Midwifery, University of Leuven, Leuven, Belgium
| | - Theo van Achterberg
- Academic Centre of Nursing and Midwifery, University of Leuven, Leuven, Belgium
| | - Tim Opgenhaffen
- Institute for Social Law, University of Leuven, Leuven, Belgium
| | - Sara Nijs
- Parenting and Special Education, University of Leuven, Leuven, Belgium
| | - Tine Peeters
- LUCAS - Centre for Care Research & Consultancy, University of Leuven, Leuven, Belgium
| | - Johan Put
- Institute for Social Law, University of Leuven, Leuven, Belgium
| | - Bea Maes
- Parenting and Special Education, University of Leuven, Leuven, Belgium
| | - Chantal Van Audenhove
- LUCAS - Centre for Care Research & Consultancy, University of Leuven, Leuven, Belgium
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27
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Hansen A, Hazelton M, Rosina R, Inder K. What do we know about the experience of seclusion in a forensic setting? An integrative literature review. Int J Ment Health Nurs 2022; 31:1109-1124. [PMID: 35384224 PMCID: PMC9543699 DOI: 10.1111/inm.13002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 11/30/2022]
Abstract
Seclusion is used in forensic and general mental health settings to protect a person or others from harm. However, seclusion can result in trauma-related harm and re-traumatization with little known about the experience of seclusion for consumers in forensic mental health settings from their perspectives. This article explores consumer experiences of seclusion in forensic mental health settings and explores the differences between female and male experiences of seclusion. Five electronic databases were systematically searched using keywords and variations of experience, attitude, seclusion, coercion, forensic mental health, and forensic psychiatry. Inclusion criteria were original peer-reviewed studies conducted in adult forensic mental health settings reporting data on the experiences of or attitudes towards seclusion. Seven studies met the criteria for inclusion and a quality assessment was undertaken. Results found consumers in forensic mental health settings perceive seclusion to be harmful, a punishment for their behaviour, and largely a negative experience that impacts their emotional health. Some consumers report positive experiences of seclusion. Differences in the experience of seclusion for females and males are unclear. Further research is required to understand the experience of seclusion for women in forensic mental health settings. Identification and consideration of differences in the experience of seclusion for males and females may assist in identifying sex-specific interventions and may inform policy and practices to eliminate or reduce the trauma associated with seclusion use.
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Affiliation(s)
- Alison Hansen
- School of Nursing & Midwifery, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia.,School of Nursing & Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Michael Hazelton
- School of Nursing & Midwifery, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Robyn Rosina
- Independent Researcher, Sydney, New South Wales, Australia
| | - Kerry Inder
- School of Nursing & Midwifery, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton, New South Wales, Australia
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28
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Hansen A, Hazelton M, Rosina R, Inder K. What do we know about the experience of seclusion in a forensic setting? An integrative literature review. Int J Ment Health Nurs 2022; 31:1109-1124. [PMID: 35592928 PMCID: PMC9546340 DOI: 10.1111/inm.13022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 11/26/2022]
Abstract
Seclusion is used in forensic and general mental health settings to protect a person or others from harm. However, seclusion can result in trauma-related harm and re-traumatization with little known about the experience of seclusion for consumers in forensic mental health settings from their perspectives. This article explores consumer experiences of seclusion in forensic mental health settings and explores the differences between female and male experiences of seclusion. Five electronic databases were systematically searched using keywords and variations of experience, attitude, seclusion, coercion, forensic mental health, and forensic psychiatry. Inclusion criteria were original peer-reviewed studies conducted in adult forensic mental health settings reporting data on the experiences of or attitudes towards seclusion. Seven studies met the criteria for inclusion and a quality assessment was undertaken. Results found consumers in forensic mental health settings perceive seclusion to be harmful, a punishment for their behaviour, and largely a negative experience that impacts their emotional health. Some consumers report positive experiences of seclusion. Differences in the experience of seclusion for females and males are unclear. Further research is required to understand the experience of seclusion for women in forensic mental health settings. Identification and consideration of differences in the experience of seclusion for males and females may assist in identifying sex-specific interventions and may inform policy and practices to eliminate or reduce the trauma associated with seclusion use.
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Affiliation(s)
- Alison Hansen
- School of Nursing & Midwifery, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia.,School of Nursing & Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Michael Hazelton
- School of Nursing & Midwifery, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Robyn Rosina
- Independent Researcher, Sydney, New South Wales, Australia
| | - Kerry Inder
- School of Nursing & Midwifery, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton, New South Wales, Australia
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29
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Dickens GL, Hosie L. Coercive containment measures for the management of self-cutting versus general disturbed behaviour: Differences in use and attitudes among mental health nursing staff. Int J Ment Health Nurs 2022; 31:962-973. [PMID: 35434806 PMCID: PMC9321753 DOI: 10.1111/inm.13006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 03/25/2022] [Accepted: 03/29/2022] [Indexed: 11/29/2022]
Abstract
Self-harm is common in mental health facilities, and coercive containment measures are sometimes used to manage it. Nurses' attitudes towards these measures have been investigated in relation to disturbed behaviour in general, but rarely to self-harm specifically. We therefore investigated mental health nurses' use of and attitudes towards coercive measures (seclusion, restraint, intermittent and constant observations, forced intramuscular medication, and PRN medication) for self-cutting management compared with for disturbed behaviours in general using a cross-sectional, repeated measures survey design. Participants were N = 164 mental health nursing staff. Data collection was via a questionnaire comprising validated attitudinal measures. The study is reported in line with STROBE guidelines. Physical restraint (36.6%), forced intramuscular medication (32.3%) and seclusion (48.2%) had reportedly been used by individuals for self-cutting management. Respondents disapproved of using each coercive measure for self-cutting more than they did for disturbed behaviour in general with the exception of PRN medication. Attitudes to coercive measures differed across target behaviours. Hence, nurses who had used each measure for managing self-cutting disapproved of it less for that purpose than those who had not. Nurses who had used coercive techniques for self-cutting management had less desirable attitudes to their use. We cannot say whether prior use of these techniques led to increased approval or whether greater approval led to an increased willingness to use them. Reducing the use of coercive techniques for self-harm will require attitudes that support its use to be challenged. Less coercive techniques should be encouraged. Harm reduction techniques offer one such alternative.
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Affiliation(s)
| | - Leah Hosie
- Mental Health Nursing, Abertay University, Dundee, UK
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30
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Martin K, Arbour S, McGregor C, Rice M. Silver linings: Observed reductions in aggression and use of restraints and seclusion in psychiatric inpatient care during COVID-19. J Psychiatr Ment Health Nurs 2022; 29:381-385. [PMID: 33704877 PMCID: PMC8242738 DOI: 10.1111/jpm.12752] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 01/25/2021] [Accepted: 03/03/2021] [Indexed: 01/09/2023]
Abstract
WHAT IS KNOWN ABOUT THE SUBJECT?: In a survey conducted by the World Health Organization (WHO) in the summer of 2020, 93% of countries worldwide acknowledged negative impacts on their mental health services. Previous research during the H1N1 pandemic in 2009 established an increase of patient aggression in psychiatric facilities. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Despite expected worsening of mental health, our hospital observed reductions in aggressive behaviour among inpatients and subsequent use of coercive interventions by staff in the months following Covid-19 pandemic restrictions being implemented. The downward trend in incidents observed during the pandemic has suggested that aggression in mental health hospitals may be more situation-specific and less so a factor of mental illness. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: We believe that the reduction in aggressive behaviour observed during the pandemic is related to changes in our organization that occurred in response to concerns about patient well-being; our co-design approach shifted trust, choice and power. Therefore, practices that support these constructs are needed to maintain the outcomes we experienced. Rather than return to normal in the wake of the pandemic, we are strongly encouraged to sustain the changes we made and continue to find better ways to support and work with the individuals who rely on or use our services. ABSTRACT: The global COVID-19 pandemic has dramatically changed the operation of health care such that many services were put on hold as patients were triaged differently, people delayed seeking care, and transition to virtual care was enacted, including in psychiatric facilities. Most of the media dialogue has been negative; however, there have been some silver linings observed. Coinciding with the pandemic has been a reduction in aggressive incidents at our psychiatric hospital, along with the decreased need to use restraints and seclusion to manage behaviour. In this paper, we are taking stock of the changes that have occurred in response to the pandemic in an attempt to share our learnings and offer suggestions so that health care does not necessarily return to "normal".
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Affiliation(s)
- Krystle Martin
- Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada.,Ontario Tech University, Oshawa, ON, Canada
| | - Simone Arbour
- Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada
| | - Carolyn McGregor
- Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada.,Ontario Tech University, Oshawa, ON, Canada
| | - Mark Rice
- Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada
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31
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Williams R, Haeney O. Does ending night-confinement reduce use of seclusion and prevalence of violence in a forensic psychiatric hospital? A retrospective observational study. Psychiatr Psychol Law 2022; 30:123-132. [PMID: 36950190 PMCID: PMC10026744 DOI: 10.1080/13218719.2021.2003265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Forensic psychiatry services strive to reduce the use of restrictive practices, and balance its occasionally necessary use with the creation of a therapeutic environment. There is limited research into the effects of least restrictive practice in forensic settings. The present retrospective observational study reviews the incidents of seclusion, restraint, and violence in a forensic psychiatric hospital one year before and one year after the introduction of a policy which ended night-confinement and allowed patients to exit their rooms overnight. The results show that there were fewer episodes of seclusion and fewer hours spent in seclusion post policy change, however this difference was not significant. There was no statistically significant difference in incidents of violence or in the use of physical restraint. While the research is of a small scale, it does suggest that policies ending night-confinement do not lead to increased seclusion episodes and encourages future research in this area.
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Affiliation(s)
| | - Owen Haeney
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
- Forensic Mental Health Service, University of Adelaide, Adelaide, SA, Australia
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
- Northern Adelaide Local Health Network, Adelaide, SA, Australia
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32
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Flammer E, Hirsch S, Thilo N, Steinert T. "Our Patients Are Different": Predictors of Seclusion and Restraint in 31 Psychiatric Hospitals. Front Psychiatry 2022; 13:791333. [PMID: 35558428 PMCID: PMC9086971 DOI: 10.3389/fpsyt.2022.791333] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 03/08/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Research in recent years has demonstrated that the use of coercive measures such as seclusion and restraint differs very much between hospitals within a country. In 2015, a central register for all coercive measures in the German federal state of Baden-Wuerttemberg has been established for 32 hospitals treating involuntary patients. The objective of the present study was to identify factors that determine the differences between these hospitals. METHODS Data on coercive measures and diagnoses from the central register in 2015-2017 were linked with structural data of the 32 hospitals and their supply areas. RESULTS On average, coercive measures were applied in 6.7% of cases (SD = 2.8%; Min-Max = 0.35-12.0%). The proportion of affected cases was significantly correlated with the proportion of involuntary patients (r = 0.56), the proportion of cases with affective or neurotic, stress-related and somatoform disorders (r = -0.42), number of hospital beds (r = 0.44), a sheltered home associated with the hospital (r = 0.43) and number of addiction counseling centers per 100,000 inhabitants in the service area (r = -0.39). The final regression model only included the proportion of involuntary cases as a significant predictor (standardized beta = 0.55, adjusted R 2 = 0.27). CONCLUSIONS The predominating part of the considerable variance observed between hospitals could not be explained by structural variables. The proportion of involuntary patients had a significant impact, but a considerable amount of unexplained variance due to different practices within psychiatric hospitals remains.
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Affiliation(s)
- Erich Flammer
- Clinic for Psychiatry and Psychotherapy I, Ulm University, Ulm, Germany.,Centres for Psychiatry Suedwuerttemberg, Ravensburg, Germany
| | - Sophie Hirsch
- Clinic for Psychiatry and Psychotherapy I, Ulm University, Ulm, Germany.,Centres for Psychiatry Suedwuerttemberg, Ravensburg, Germany
| | - Nancy Thilo
- Clinic for Psychiatry and Psychotherapy I, Ulm University, Ulm, Germany
| | - Tilman Steinert
- Clinic for Psychiatry and Psychotherapy I, Ulm University, Ulm, Germany.,Centres for Psychiatry Suedwuerttemberg, Ravensburg, Germany
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33
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Vruwink FJ, VanDerNagel JEL, Noorthoorn EO, Nijman HLI, Mulder CL. "Disruptive Behavior" or "Expected Benefit" Are Rationales of Seclusion Without Prior Aggression. Front Psychiatry 2022; 13:871525. [PMID: 35492701 PMCID: PMC9051060 DOI: 10.3389/fpsyt.2022.871525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE In the Netherlands, seclusion of patients with a psychiatric disorder is a last-resort measure to be used only in the event of (imminent) severe danger or harm. Although aggressive behavior is often involved, seclusions not preceded by aggression also seem to occur. We sought insight into the non-aggressive reasons underlying seclusion and investigated the factors associated with it. METHOD We included all patients admitted to a Dutch psychiatric hospital in 2008 and 2009. Seclusions had been registered on Argus-forms, and aggression incidents had been registered on the Staff Observation Aggression Scale-Revised (SOAS-R), inspectorate forms and/or patient files. Determinants of seclusion with vs. without prior aggression were analyzed using logistic regression. Reasons for seclusion without prior aggression were evaluated qualitatively and grouped into main themes. RESULTS Of 1,106 admitted patients, 184 (17%) were secluded at some time during admission. Twenty-one (11.4%) were excluded because information on their seclusion was lacking. In 23 cases (14%), neither SOAS-R, inspectorate forms nor individual patient files indicated any aggression. Univariable and multivariable regression both showed seclusion without preceding aggression to be negatively associated with daytime and the first day of hospitalization. In other words, seclusion related to aggression occurred more on the first day, and during daytime, while seclusion for non-aggressive reasons occurred relatively more after the first day, and during nighttime. Our qualitative findings showed two main themes of non-aggressive reasons for seclusion: "disruptive behavior" and "beneficial to patient." CONCLUSION Awareness of the different reasons for seclusion may improve interventions on reducing its use. Thorough examination of different sources showed that few seclusions had not been preceded by aggression. The use of seclusion would be considerably reduced through interventions that prevent aggression or handle aggression incidents in other ways than seclusion. However, attention should also be paid to the remaining reasons for seclusion, such as handling disruptive behavior and focusing on the beneficial effects of reduced stimuli. Future research on interventions to reduce the use of seclusion should not only aim to reduce seclusion but should also establish whether seclusions preceded by aggression decrease different from seclusions that are not preceded by aggression.
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Affiliation(s)
- Fleur J Vruwink
- Mediant Geestelijke Gezondheidszorg (GGZ), Enschede, Netherlands
| | - Joanneke E L VanDerNagel
- Tactus, Deventer, Netherlands.,Department of Human Media Interactions, University of Twente, Enschede, Netherlands.,Aveleijn, Borne, Netherlands.,Nijmegen Institute for Scientist-Practitioners in Addiction, Radboud Universiteit Nijmegen, Nijmegen, Netherlands
| | | | - Henk L I Nijman
- Clinical Psychology, Department of Social Sciences, Behavioural Science Institute (BSI), Radboud University, Nijmegen, Netherlands
| | - Cornelis L Mulder
- Department of Psychiatry, Epidemiologic and Social Psychiatry Research Institute (ESPRI), Erasmus MC, Rotterdam, Netherlands
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Ruud T, Haugom EW, Pincus HA, Hynnekleiv T. Measuring Seclusion in Psychiatric Intensive Care: Development and Measurement Properties of the Clinical Seclusion Checklist. Front Psychiatry 2021; 12:768500. [PMID: 35002798 PMCID: PMC8733687 DOI: 10.3389/fpsyt.2021.768500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/23/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Acute psychiatric units in general hospitals must ensure that acutely disturbed patients do not harm themselves or others, and simultaneously provide care and treatment and help patients regain control of their behavior. This led to the development of strategies for the seclusion of a patient in this state within a particular area separated from other patients in the ward. While versions of this practice have been used in different countries and settings, a systematic framework for describing the various parameters and types of seclusion interventions has not been available. The aims of the project were to develop and test a valid and reliable checklist for characterizing seclusion in inpatient psychiatric care. Methods: Development and testing of the checklist were accomplished in five stages. Staff in psychiatric units completed detailed descriptions of seclusion episodes. Elements of seclusion were identified by thematic analysis of this material, and consensus regarding these elements was achieved through a Delphi process comprising two rounds. Good content validity was ensured through the sample of seclusion episodes and the representative participants in the Delphi process. The first draft of the checklist was revised based on testing by clinicians assessing seclusion episodes. The revised checklist with six reasons for and 10 elements of seclusion was tested with different response scales, and acceptable interrater reliability was achieved. Results: The Clinical Seclusion Checklist is a brief and feasible tool measuring six reasons for seclusion, 10 elements of seclusion, and four contextual factors. It was developed through a transparent process and exhibited good content validity and acceptable interrater reliability. Conclusion: The checklist is a step toward achieving valid and clinically relevant measurements of seclusion. Its use in psychiatric units may contribute to quality assurance, more reliable statistics and comparisons across sites and periods, improved research on patients' experiences of seclusion and its effects, reduction of negative consequences of seclusion, and improvement of psychiatric intensive care.
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Affiliation(s)
- Torleif Ruud
- Mental Health Services, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Espen Woldsengen Haugom
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Acute Psychiatry and Psychosis Treatment, Sanderud, Division of Mental Health, Innlandet Hospital Trust, Ottestad, Norway
| | - Harold Alan Pincus
- Department of Psychiatry and Irving Institute for Clinical and Translational Research, Columbia University, New York City, NY, United States
- New York State Psychiatric Institute, New York City, NY, United States
| | - Torfinn Hynnekleiv
- Department of Acute Psychiatry and Psychosis Treatment, Division of Mental Health, Innlandet Hospital Trust, Reinsvoll, Norway
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Laukkanen E, Kuosmanen L, Louheranta O, Ryynänen OP, Vehviläinen-Julkunen K. A Bayesian network model to identify the associations between the use of seclusion in psychiatric care and nursing managers' attitudes towards containment methods. J Psychiatr Ment Health Nurs 2021; 28:815-828. [PMID: 33547840 DOI: 10.1111/jpm.12736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 01/27/2021] [Accepted: 02/02/2021] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN ON THE SUBJECT Seclusion is used frequently in psychiatric care, despite its potential adverse effects. Several programmes aiming to reduce the use of seclusion identify leadership and management as key strategies-however, studies concerning leaders and managers are missing. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE Nursing managers' negative attitudes towards seclusion are associated with less use of the measure, and nursing managers' higher age is associated with increased use of seclusion. WHAT ARE THE IMPLICATIONS FOR PRACTICE Nursing managers should be encouraged to guide their staff to reduce the use of seclusion. The negative influences of seclusion and the potential of alternative measures should be highlighted in the education and training of psychiatric nursing managers. ABSTRACT Introduction The use of seclusion in psychiatric care should be reduced. The relationship between nursing management or nursing managers' attitudes and the use of seclusion has not been investigated. Aim To describe the associations between the use of seclusion and psychiatric nursing managers' attitudes to containment methods. Method Register data concerning the use of seclusion in Finnish psychiatric care in 2017 were collected. The Attitudes to Containment Measures Questionnaire was used to illustrate psychiatric nursing managers' attitudes to containment methods. An Augmented Naive Bayes analysis was used to investigate the relationships of the use of seclusion and attitudes. Results Nursing managers' age and their attitudes towards containment methods were related to the use of seclusion. Especially nursing managers' negative perceptions of seclusion were associated with less use of seclusion, and seclusion was used more often on wards with nursing managers who were older than the average. Conclusion Nursing managers' negative attitudes towards seclusion have a potential impact on the use of seclusion, which might even result in a reduction in its use in psychiatric inpatient setting. Implications for practice The results suggest that nursing managers should be encouraged to guide their staff to decrease the use of seclusion.
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Affiliation(s)
- Emilia Laukkanen
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland.,Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland.,Finnish Medicines Agency Fimea, Kuopio, Finland
| | - Lauri Kuosmanen
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
| | - Olavi Louheranta
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
| | - Olli-Pekka Ryynänen
- Department of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland.,General Practice Unit, Kuopio University Hospital, Primary Health Care, Kuopio, Finland
| | - Katri Vehviläinen-Julkunen
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland.,Kuopio University Hospital, Kuopio, Finland
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Ayres S, Tracy MF. Recovery Model Implementation for a Medical/Geriatric Psychiatric Unit to Decrease Restraint and Seclusion Episodes: A Quality Improvement Project. J Am Psychiatr Nurses Assoc 2021; 27:355-360. [PMID: 34651520 DOI: 10.1177/10783903211048449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION In inpatient behavioral health units, a long-standing behavioral management controversy has been whether to physically restrain or seclude patients. The rate of restraint use at the institution underperformed compared with the national average, which led to the project implementation. AIMS This quality improvement project's objective was to decrease restraint and seclusion use, improve quality of care, and decrease cost through implementation of recovery model principles. METHOD Implementation started in October 2019 on a 14-bed inpatient medical/geriatric psychiatric unit with 38 psychiatric RNs at a large academic medical center. The project was a pre-post implementation design with interventions consisting of staff education, RN language observation, and orientation toolkit development. Changes in staff knowledge were measured by Recovery Knowledge Inventory surveys at baseline, 1 week posteducation, and 4 months posteducation. Restraint and seclusion use data were analyzed 3 months preimplementation and 3 months postimplementation. RESULTS Staff knowledge of the recovery model increased from baseline to 1 week postimplementation in all four survey domains (range = 6% to 9% improvement). While improvements were maintained in two survey domains, two domains of staff knowledge showed slight declines (1% to 2% decline in scores) 4 months postintervention. Restraint use decreased 73.1% and seclusion use decreased 16.3% from pre to postintervention. CONCLUSION Implementation of recovery model principles can decrease restraint and seclusion episodes, which increases quality and decreases cost to the organization.
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Affiliation(s)
- Sara Ayres
- Sara Ayres, DNP, MS, RN, Mayo Clinic, Rochester, MN, USA
| | - Mary Fran Tracy
- Mary Fran Tracy, PhD, RN, APRN, CNS, FCNS, FAAN, University of Minnesota Twin Cities, Minneapolis, MN, USA
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Spencer S, Kable A, Stone T, McMillan M. Nurses' responses to adolescent distress in an acute child and adolescent mental health inpatient unit: A qualitative interpretive descriptive study. J Child Adolesc Psychiatr Nurs 2021; 34:352-359. [PMID: 34216414 DOI: 10.1111/jcap.12342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/11/2021] [Accepted: 05/31/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To describe observed nursing responses and interventions to adolescent inpatients experiencing distress. METHODS Thorne's interpretive descriptive approach guided data collection and analysis of nonparticipant observations of a purposive sample of adolescents, and nurses. FINDINGS Three major themes are presented: engagement: responses and interventions for working with distress; adolescent reactions and nurses' clinical decision making to manage distress; and outcomes: escalation or resolution of distress. CONCLUSIONS The TAR3 conceptual model developed from this study can guide nurses' responses to distressed adolescents and promote safety, enhance positive outcomes, and reduce the use of coercive interventions.
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Affiliation(s)
- Stephen Spencer
- School of Nursing & Midwifery, University of Newcastle, Callaghan, New South Wales, Australia
| | - Ashley Kable
- School of Nursing & Midwifery, University of Newcastle, Callaghan, New South Wales, Australia
| | - Teresa Stone
- Faculty of Nursing, Chang Mai University, Chang Mai, Thailand
| | - Margaret McMillan
- School of Nursing & Midwifery, University of Newcastle, Callaghan, New South Wales, Australia
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Albers C, Nair N, Shankar R. Antipsychotics in Inpatient Children and Adolescents with Seclusion and Restraint: A Preliminary Exploratory Retrospective Chart Review. J Child Adolesc Psychopharmacol 2021; 31:358-363. [PMID: 34143681 DOI: 10.1089/cap.2020.0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective: This study is a retrospective review of patients 5-17 years of age experiencing seclusion and/or restraint (S&R) in a pediatric psychiatric inpatient setting and an exploratory analysis of antipsychotic use on S&R duration. We examined whether administration of antipsychotics would possibly decrease the time spent in S&R. Methods: Reports of patients who underwent S&R in an acute care inpatient child and adolescent psychiatric unit from 2012 to 2014 were reviewed. Demographic information related to age, gender, and race as well as information on diagnosis, current medications (including antipsychotics) were obtained. Independent samples t-tests were used to determine whether there were differences in how much time patients spent in S&R based on whether they were administered antipsychotics or not. Odds ratios (ORs) of being administered antipsychotics during S&R were computed for factors such as gender, race, and diagnosis group. Results: Ninety-six patients (68 males, age range 5-17 years) were involved in 232 S&R events that occurred between 2012 and 2014. Results indicate that patients who were administered antipsychotics during S&R still spent significantly more time in S&R compared with those who were given medications other than antipsychotics (e.g., Benadryl) (t = 3.161; p = 0.002) and those who were not administered any medication (t = 3.54; p = 0.001). Binary logistic regression showed that female patients were at more than two times (OR(adjusted) = 2.86; 95% confidence interval = 1.234-6.655) higher risk of being administered antipsychotics while in S&R compared with their male counterparts within this particular sample. Conclusions: The results of our study indicate that, contrary to our hypothesis, antipsychotic administration did not appear to reduce the time spent in S&R compared with groups that were administered medications other than antipsychotics and those that were not administered any medication during S&R. We also found an increased risk of antipsychotic administration in female patients compared with male patients in S&R events, indicating the need for larger studies examining these effects in greater detail.
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Affiliation(s)
- Cecilia Albers
- Department of Psychiatry, University of Missouri, Columbia, Missouri, USA
| | - Neetu Nair
- Department of Psychiatry, University of Missouri, Columbia, Missouri, USA
| | - Ravi Shankar
- Department of Psychiatry, University of Missouri, Columbia, Missouri, USA
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Krieger E, Moritz S, Lincoln TM, Fischer R, Nagel M. Coercion in psychiatry: A cross-sectional study on staff views and emotions. J Psychiatr Ment Health Nurs 2021; 28:149-162. [PMID: 32348607 DOI: 10.1111/jpm.12643] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/12/2020] [Accepted: 04/17/2020] [Indexed: 01/03/2023]
Abstract
WHAT IS KNOWN ON THE SUBJECT?: Coercive interventions (CI) in emergency psychiatry face increasing criticism, as they can be an emotional, even traumatic event for all persons involved. They are thus considered the last resort. The use of coercive interventions differs widely with regard to type and frequency of measures across different countries and institutions. Individual staff characteristics, such as attitudes towards coercion, may play a vital role in the management of aggression. Little is known about the influence of emotions of staff members on CI, but they are likely to play an important role. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Most staff members surveyed had a rather critical view of coercion and considered it a "necessary evil." Staff members with the most work experience had a more critical view of coercion in comparison with less experienced staff. Nurses rated coercion more positively than did psychiatrists or psychologists. Emotions play an important role in decision-making processes. The current study systematically asked for accompanying emotions during the application of CI and looked for individual differences. A majority of the participants experienced compassion; about half felt helplessness, grief or anxiety. Almost 20% stated that they felt a sense of power. Older staff members more often felt anger or guilt; women felt less power than men did. Nurses felt more desperation than other occupational groups. Staff members consider reflective interventions, such as team supervisions or post-seclusion/restraint debriefings with the patient, as important. Nevertheless, only half reported that these interventions are carried out routinely. Staff members believe that certain risk factors (including stress, low staffing, a fully occupied ward and the presence of particular staff members) enhance the probability of CI. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: To reduce the use of coercive interventions, we recommend that psychiatric teams include highly experienced staff members as work experience has a positive effect on the attitudes towards coercive interventions. Structured post-seclusion/restraint debriefings and team supervisions are considered helpful by staff members and are relatively easy to implement on acute wards. Enhancing staff members' ability to reflect on their own attitudes, emotions and actions is likely to reduce coercive interventions. ABSTRACT: Introduction Little is known about staff attitudes towards coercive interventions (CI) and emotions accompanying these measures. Aim The current study assessed attitudes, views on reflective interventions and accompanying emotions of different occupational groups towards CI, as well as factors, that increase the probability of CI. Method Staff members (N = 138) of a large psychiatric hospital in Germany were assessed using the Staff Attitude to Coercion Scale (SACS) and newly developed items assessing staff members' emotions and views on coercion. Results Experienced staff members were most critical of coercion. Nurses rated coercion significantly more positively than other staff. A majority experienced compassion; about half felt helplessness, grief or anxiety. Almost 20% felt a sense of power. Nurses felt the most desperation. Participants strongly desired reflective measures such as post-seclusion/restraint debriefings with patients. According to staff members, stress on the wards and low staffing increases the probability of CI. Discussion The study assessed accompanying emotions during the application of CI. Attitudes towards coercion and emotions are associated with individual staff characteristics (e.g. profession, work experience). Implications The presence of experienced staff members may help prevent CI. Staff consider reflective interventions helpful in reducing CI.
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Affiliation(s)
- Eva Krieger
- Department of Psychiatry and Psychotherapy, Asklepios Clinic Nord - Wandsbek, Hamburg, Germany.,Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Steffen Moritz
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tania M Lincoln
- Clinical Psychology and Psychotherapy, Institute of Psychology, Faculty of Psychology and Human Movement, Universität Hamburg, Hamburg, Germany
| | - Rabea Fischer
- Department of Psychiatry and Psychotherapy, Asklepios Clinic Nord - Wandsbek, Hamburg, Germany.,Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Nagel
- Department of Psychiatry and Psychotherapy, Asklepios Clinic Nord - Wandsbek, Hamburg, Germany.,Department of Psychiatry and Psychotherapy, University Medical Center Schleswig-Holstein, Luebeck, Germany
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Mathew AM, Robert S, Ross C, Weeda E, Pruitt A. Impact of holding home stimulant(s) on agitation in a child and adolescent inpatient psychiatric population. Ment Health Clin 2021; 11:50-54. [PMID: 33850682 PMCID: PMC8019544 DOI: 10.9740/mhc.2021.03.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction This study aimed to compare the rates of agitation-related interventions associated with initial holding versus continuation of home stimulant(s) in a child and adolescent population at the time of admission to an inpatient psychiatric facility. Methods This retrospective chart review included patients less than 18 years of age who were admitted to an academic medical center between July 1, 2017, and July 1, 2018. Patients were divided into 2 groups: those continued on their home stimulant(s) and those who had them held. We compared both groups on agitation-related outcomes by examining the difference in the number of level I or II events or as-needed medication administrations. Mechanical restraints and closed-door seclusions were grouped as level I events, and level II events consisted of nonmechanical restraint. Results The analysis included 169 patients. In total, 126 (75%) patients were continued on their home stimulant, and 43 (25%) had them held. The occurrence of the composite endpoint of level I or II events or as-needed intramuscular medication administration was numerically higher in the group that had their home stimulant held (27.9% vs 23%; P = .52). Level I events were also numerically higher but not statistically significant in the group that had their home stimulant held (16.3% vs 11.9%; P = .46). Discussion The composite outcome of as-needed intramuscular medication administration and level I or II events was numerically higher in the group that had their home stimulant held. Use of a larger sample size and adjusted analyses may help elucidate covariates that impact agitation-related outcomes.
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Affiliation(s)
- Anupha M Mathew
- Clinical Pharmacy Resident, Medical University of South Carolina Health, Charleston, South Carolina,
| | - Sophie Robert
- Clinical Pharmacy Specialist - Psychiatry, Medical University of South Carolina Health, Charleston, South Carolina; Research Assistant Professor, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina; Adjunct Assistant Professor, Medical University of South Carolina, College of Pharmacy, Charleston, South Carolina
| | - Clint Ross
- Clinical Pharmacy Specialist - Psychiatry, Medical University of South Carolina Health, Charleston, South Carolina; Affiliate Associate Professor, Medical University of South Carolina, College of Pharmacy, Charleston, South Carolina
| | - Erin Weeda
- Assistant Professor, College of Pharmacy, Medical University of South Carolina Health, Charleston, South Carolina
| | - Adrienne Pruitt
- Assistant Professor, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina Health, Charleston, South Carolina
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Morisset J. [Nursing clinical judgement in situations of restraint]. Soins 2021; 66:52-54. [PMID: 33775305 DOI: 10.1016/s0038-0814(21)00061-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Coercive measures such as seclusion and restraint, which are sometimes used in psychiatry, remain current practices. According to literature, these interventions are particularly complex for the nurses implementing them. In situations of seclusion and restraint, these professionals focus in particular on the nurse-patient relationship, the patient's safety and the respect of their humanity. Training is possible to help nurses manage these situations and improve their approach to the clinical judgement.
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Affiliation(s)
- Jérôme Morisset
- Établissement public de santé mentale de Vendée, centre hospitalier Georges-Mazurelle, rue d'Aubigny, 85000 La Roche-sur-Yon, France.
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Yurtbasi MK, Melvin G, Pavlou C, Gordon M. Nurse and patient factors: Predicting seclusion in adolescent psychiatric units. J Child Adolesc Psychiatr Nurs 2021; 34:112-119. [PMID: 33393691 DOI: 10.1111/jcap.12306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/13/2020] [Indexed: 11/30/2022]
Abstract
PROBLEM Seclusion is considered a necessity when alternatives have failed. There is a consensus that seclusion has no therapeutic benefit, which justifies efforts to reduce the practice. This study aimed to identify nurse and patient variables that are predictive of seclusion on a large adolescent inpatient unit. METHODS Nested case controls were used to compare 72 afternoon shifts on which seclusion occurred to 216 afternoon shifts on which no seclusion occurred, between 2010 and 2013, at an Adolescent Psychiatric Inpatient Unit. FINDINGS Increased seclusion was predicted by a lower nurse to patient ratio, more male nurses on shift, fewer female nurses on shift, the presence of agency/temporary nurses on shift, greater combined years of mental health experience, and lower total HoNOSCA behavior subscale score. Unique predictors that increased risk of seclusion included greater number of male nurses and the presence of agency/temporary nurses, while a greater number of female nurses decreased risk of seclusion. CONCLUSIONS Nurses play a unique role in seclusion outcomes that are separate to patient-factors and act as both protective and risk factors for seclusion. Changes can be made to staffing to reduce seclusion and future research should investigate why these nurse-factors contribute to seclusion.
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Affiliation(s)
- Miriam K Yurtbasi
- Department of Psychiatry, Centre for Developmental Psychiatry and Psychology, School of Clinical Sciences, Monash University, Clayton, Australia
| | - Glenn Melvin
- School of Psychology, Faculty of Health, Deakin University, Burwood, Australia
| | - Christine Pavlou
- Psychiatric Services at Monash Health, Early in Life Mental Health Service, Monash Children's Hospital, Clayton, Australia
| | - Michael Gordon
- Department of Psychiatry, Centre for Developmental Psychiatry and Psychology, School of Clinical Sciences, Monash University, Clayton, Australia.,Psychiatric Services at Monash Health, Early in Life Mental Health Service, Monash Children's Hospital, Clayton, Australia
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Padilla E, Lordeon PA. Technical Tips: Restraint Use in Healthcare - What Neurodiagnostic Technologists Need to Know. Neurodiagn J 2021; 61:61-71. [PMID: 33382632 DOI: 10.1080/21646821.2021.1845058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
In healthcare, it is not uncommon for neurodiagnostic technologists to provide care and testing for patients who are in restraints or in need of restraints. When properly used, restraints ensure patient safety and the safety of others while allowing the continuation of life saving tests and treatments. Oversight for restraint use is provided by outside agencies such as the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC). Improper use of restraints can lead to serious sanctions by both organizations and can negatively impact patients, leaving them with emotional and psychological trauma. The process of restraint management such as ordering, implementing, or monitoring restrained patients is not within the scope of practice for neurodiagnostic technologists. Restraints should only be utilized as a last resort for the safety of the patient to receive proper care. This paper seeks to inform Technologists on what does and does not constitute a restraint, and the factors that should be considered before making the decision to request use of restraints in order to perform neurodiagnostic testing.
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Affiliation(s)
- Erik Padilla
- Neurodiagnostic Services, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Patricia A Lordeon
- Epilepsy Monitoring Unit, University of Pittsburgh Medical Center Presbyterian Hospital, Pittsburgh, Pennsylvania
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Gemsa S, Noorthoorn EO, Lepping P, de Haan HA, Wierdsma AI, Hutschemaekers GJM. The Compulsory Care Act: Early Observations and Expectations of In- or Outpatient Involuntary Treatment. Front Psychiatry 2021; 12:770934. [PMID: 35222103 PMCID: PMC8864544 DOI: 10.3389/fpsyt.2021.770934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 12/27/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND On January 1, 2020, the Dutch Compulsory Care Act (WvGGZ) replaced the Special Admissions Act (BOPZ). While the old law only allowed compulsory treatment in hospitals, the new law allows it both inside and outside the hospital. Moreover, the new law prioritizes the patient's own opinion on coercive measures. By following patients' own choices, the Compulsory Care Act is hoped to lead to fewer admission days and less inpatient compulsory treatment in involuntarily admitted patients. METHODS We studied the seclusion and enforced-medication events before and after January 1, 2020, using coercive measures monitoring data in a Mental Health Trust. Trends in hours of seclusion and the number of enforced-medication events per month from 2012 to 2019 were compared with 2020. We used generalized linear models to perform time series analysis. Logistic regression analyses and generalized linear models were performed to investigate whether patient compilation determined some of the observed changes in seclusion use or enforced-medication events. RESULTS The mean number of hours of seclusion between 2012 and 2019 was 27,124 per year, decreasing from 48,542 in 2012 to 21,133 in 2019 to 3,844 h in 2020. The mean incidence of enforced-medication events between 2012 and 2019 was 167, increasing from 90 in 2012 to 361 in 2019 and then fell to 294 in 2020. In 2020, we observed 3,844 h of seclusion and 294 enforced-medication events. Near to no outpatient coercion was reported, even though it was warranted. The time series analysis showed a significant effect of the year 2020 on seclusion hours (β = -1.867; Exp(β) = 0.155, Wald = 27.22, p = 0.001), but not on enforced-medication events [β = 0.48; Exp(β) = 1.616, Wald = 2.33, p = 0.13]. DISCUSSION There was a reduction in the number of seclusion hours after the introduction of the Compulsory Care Act. The number of enforced-medication events also increased from a very low baseline, but from 2017 onwards. To see whether these findings are consistent over time, they need to be replicated in the near future. CONCLUSION We observed a significant increase in enforced-medication use and a decrease in seclusion hours. The year 2020 predicted seclusion hours, but not enforced-medication events.
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Affiliation(s)
- Stephan Gemsa
- Ggnet Mental Health Institute, Child Psychiatry Service, Warnsveld, Netherlands
| | - Eric O Noorthoorn
- Ggnet Mental Health Institute, Child Psychiatry Service, Warnsveld, Netherlands
| | - Peter Lepping
- Betsi Cadwaladr University Health Board, Wrexham, United Kingdom.,Wrexham Academic Unit, Centre for Mental Health and Society, Bangor University, Wrexham, United Kingdom.,Mysore Medical College and Research Institute, Mysuru, India
| | - Hein A de Haan
- Ggnet Mental Health Institute, Child Psychiatry Service, Warnsveld, Netherlands.,Tactus Verslavingszorg, Addiction Care and Treatment Service, Deventer, Netherlands
| | - Andre I Wierdsma
- Department of Psychiatry, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Giel J M Hutschemaekers
- Behavioral Science Institute, University of Nijmegen, Nijmegen, Netherlands.,Pro Persona Mental Health Care, Indigo Centre, Nijmegen, Netherlands
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Abstract
Introduction: Coercion is frequent in clinical practice, particularly in psychiatry. Since it overrides some fundamental rights of patients (notably their liberty of movement and decision-making), adequate use of coercion requires legal and ethical justifications. In this article, we map out the ethical elements used in the literature to justify or reject the use of coercive measures limiting freedom of movement (seclusion, restraint, involuntary hospitalization) and highlight some important issues. Methods: We conducted a narrative review of the literature by searching the PubMed, Embase, PsycINFO, Google Scholar and Cairn.info databases with the keywords "coercive/compulsory measures/care/treatment, coercion, seclusion, restraint, mental health, psychiatry, involuntary/compulsory hospitalization/admission, ethics, legitimacy." We collected all ethically relevant elements used in the author's justifications for or against coercive measures limiting freedom of movement (e.g., values, rights, practical considerations, relevant feelings, expected attitudes, risks of side effects), and coded, and ordered them into categories. Results: Some reasons provided in the literature are presented as justifying an absolute prohibition on coercion; they rely on the view that some fundamental rights, such as autonomy, are non-negotiable. Most ethically relevant elements, however, can be used in a balanced weighting of reasons to favor or reject coercive measures in certain circumstances. Professionals mostly agree that coercion is only legitimate in exceptional circumstances, when the infringement of some values (e.g., freedom of movement, short-term autonomy) is the only means to fulfill other, more important values and goals (e.g., patient's safety, the long-term rebuilding of patient's identity and autonomy). The results of evaluations vary according to which moral elements are prioritized over others. Moreover, we found numerous considerations (e.g., conditions, procedural values) for how to ensure that clinicians apply fair decision-making procedures related to coercion. Based on this analysis, we highlight vital topics that need further development. Conclusion: Before using coercive measures limiting freedom of movement, clinicians should consider and weigh all ethically pertinent elements in the situation and actively search for alternatives that are more respectful of patient's well-being and rights. Coercive measures decided upon after a transparent, carefully balanced evaluation process are more likely to be adequate, understood, and accepted by patients and caregivers.
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Affiliation(s)
- Marie Chieze
- Adult Psychiatry Service, Department of Psychiatry, University Hospitals of Geneva, Geneva, Switzerland
| | - Christine Clavien
- iEH2-Institute of Ethics History Humanities, University of Geneva, Geneva, Switzerland
| | - Stefan Kaiser
- Adult Psychiatry Service, Department of Psychiatry, University Hospitals of Geneva, Geneva, Switzerland
| | - Samia Hurst
- iEH2-Institute of Ethics History Humanities, University of Geneva, Geneva, Switzerland
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Silva E, Higgins M, Hammer B, Stephenson P. Clozapine re-challenge and initiation following neutropenia: a review and case series of 14 patients in a high-secure forensic hospital. Ther Adv Psychopharmacol 2021; 11:20451253211015070. [PMID: 34221348 PMCID: PMC8221694 DOI: 10.1177/20451253211015070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 04/16/2021] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Clozapine remains the most effective intervention for treatment resistant schizophrenia; however, its use is prohibited following neutropenias. We review neutrophil biology as applied to clozapine and describe the strategies to initiate clozapine following neutropenia used in a case series of 14 consecutive patients rechallenged in a United Kingdom (UK) high-secure psychiatric hospital. We examine outcomes including the use of seclusion and transfer. METHODS A case series of 14 male patients with treatment resistant schizophrenia treated with clozapine despite previous episodes of neutropenia between 2006 and 2015 is presented. Data were collected during 2015 and 2019. Using this routinely collected clinical data, we describe the patient characteristics, causes of neutropenia, the strategies used for rechallenging with clozapine and clinical outcomes. RESULTS Previous neutropenias were the result of benign ethnic neutropenia, clozapine, other medications and autoimmune-related. Our risk mitigation strategies included: granulocyte-colony stimulating factor (G-CSF), lithium and watch-and-wait. There were no serious adverse events; at follow up half of the patient's had improved sufficiently to transfer them to conditions of lesser security. There were dramatic reductions in the use of seclusion. CONCLUSION Even in this extreme group, clozapine can be safely and effectively re/initiated following neutropenias, resulting in marked benefits for patients. This requires careful planning based on an understanding of neutrophil biology and the aetiology of the specific episode of neutropenia.
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Affiliation(s)
- Edward Silva
- Rathbone Low Secure Unit, Mersey Care NHS Foundation Trust, Rathbone Hospital, Mill Lane, Liverpool, L13 4AW, UK
| | - Melanie Higgins
- Ashworth Hospital, Mersey Care NHS Foundation Trust, Liverpool, UK
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Vruwink FJ, Wierdsma A, Noorthoorn EO, Nijman HLI, Mulder CL. Number of Seclusions in the Netherlands Higher in the 7 Years Since the End of a Nationwide Seclusion-Reduction Program. Front Psychiatry 2021; 12:778793. [PMID: 34925102 PMCID: PMC8678042 DOI: 10.3389/fpsyt.2021.778793] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/04/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction: Between 2006 and 2012 the Dutch government funded a nationwide program for reducing the use of seclusion. Although an initial first trend study showed that the reported number of seclusions declined during the program, the objective of a 10% annual decrease was not met. We wished to establish whether the decline had continued after funding ended in 2012. Method: Using quasi Poisson time series modeling, we retrospectively analyzed the nationally reported numbers of seclusion and involuntary medication between 1998 and 2019, i.e., before, during and after the end of the nationwide program, with and without correction for the number of involuntary admissions. Results: With and without correction for the number of involuntary admissions, there were more seclusions in the seven years after the nationwide program than during the nationwide program. Although the reported number of involuntary medications also increased, the rate of increase was slower after the end of the nationwide program than before. Conclusions: Rather than continuing to decrease after the end of the nationwide program, the number of seclusions rose. This may mean that interventions intended to reduce the use of seclusion within this program are not properly sustained in daily clinical care without an ongoing national program.
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Affiliation(s)
| | - André Wierdsma
- Department of Psychiatry, Erasmus Medical Center, Epidemiological and Social Psychiatric Research Institute, Rotterdam, Netherlands
| | | | - Henk L I Nijman
- Department of Social Sciences, Clinical Psychology, Behavioural Science Institute, Radboud University, Nijmegen, Netherlands
| | - Cornelis L Mulder
- Department of Psychiatry, Erasmus Medical Center, Epidemiological and Social Psychiatric Research Institute, Rotterdam, Netherlands
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48
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Barbaree HE, Mathias K, Fries BE, Brown GP, Stewart SL, Ham E, Hirdes JP. The Forensic Supplement to the interRAI Mental Health Assessment Instrument: Evaluation and Validation of the Problem Behavior Scale. Front Psychiatry 2021; 12:769034. [PMID: 34966306 PMCID: PMC8711783 DOI: 10.3389/fpsyt.2021.769034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/11/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Numerous validation studies support the use of the interRAI Mental Health (MH) assessment system for inpatient mental health assessment, triage, treatment planning, and outcome measurement. However, there have been suggestions that the interRAI MH does not include sufficient content relevant to forensic mental health. We address this potential deficiency through the development of a Forensic Supplement (FS) to the interRAI MH system. Using three forensic risk assessment instruments (PCL-R; HCR-20; VRAG) that had a record of independent cross validation in the forensic literature, we identified forensic content domains that were missing in the interRAI MH. We then independently developed items to provide forensic coverage. The resulting FS is a single-page, 19-item supplementary document that can be scored along with the interRAI MH, adding approximately 10-15 min to administration time. We constructed the Problem Behavior Scale (PBS) using 11 items from the interRAI MH and FS. The Developmental Sample, 168 forensic mental health inpatients from two large mental health specialty hospitals, was assessed with both an earlier version of the interRAI MH and FS. This sample also provided us access to scores on the PCL-R, the HCR-20 and the VRAG. To validate our initial findings, we sought additional samples where scoring of the interRAI MH and the FS had been done. The first, the Forensic Sample (N = 587), consisted of forensic inpatients in other mental health units/hospitals. The second, the Correctional Sample (N = 618) was a random, representative sample of inmates in prisons, and the third, the Youth Sample (N = 90) comprised a group of youth in police custody. Results: The PBS ranged from 0 to 11, was positively skewed with most scores below 3, and had good internal consistency (Cronbach's Alpha = 0.80). In a test of concurrent validity, correlations between PBS scores and forensic risk scores were moderate to high (i.e., r with PCL-R Factor two of 0.317; with HCR-20 Clinical of 0.46; and with HCR-20 Risk of 0.39). In a test of convergent validity, we used Binary Logistic Regression to demonstrate that the PBS was related to three negative patient experiences (recent verbal abuse, use of a seclusion room, and failure to attain an unaccompanied leave). For each of these three samples, we conducted the same convergent validity statistical analyses as we had for the Developmental Sample and the earlier findings were replicated. Finally, we examined the relationship between PBS scores and care planning triggers, part of the interRAI systems Clinical Assessment Protocols (CAPs). In all three validity samples, the PBS was significantly related to the following CAPs being triggered: Harm to Others, Interpersonal Conflict, Traumatic Life Events, and Control Interventions. These additional validations generalize our findings across age groups (adult, youth) and across health care and correctional settings. Conclusions: The FS improves the interRAI MH's ability to identify risk for negative patient experiences and assess clinical needs in hospitalized/incarcerated forensic patients. These results generalize across age groups and across health care and correctional settings.
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Affiliation(s)
- Howard E Barbaree
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Waypoint Centre for Mental Health Care, Midland, ON, Canada
| | | | - Brant E Fries
- Institute of Gerontology, University of Michigan, Ann Arbor, MI, United States.,School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Greg P Brown
- Department of Criminal Justice, Nipissing University, North Bay, ON, Canada
| | - Shannon L Stewart
- Applied Psychology, Faculty of Education, Western University, London, ON, Canada
| | - Elke Ham
- Waypoint Centre for Mental Health Care, Midland, ON, Canada
| | - John P Hirdes
- Department of Health Studies and Gerontology, University of Waterloo, Waterloo, ON, Canada
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49
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Lantta T, Varpula J, Cheung T, Wong WK, Cheng PYI, Ng T, Ng CF, Yam CP, Ip G, Bressington D, Välimäki M. Prevention and management of aggressive behaviour in patients at psychiatric hospitals: a document analysis of clinical practice guidelines in Hong Kong. Int J Ment Health Nurs 2020; 29:1079-1091. [PMID: 32602160 DOI: 10.1111/inm.12742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 01/01/2023]
Abstract
Patient aggressive behaviour remains a significant public health concern worldwide. The use of restraint and seclusion remains a last resort but not an uncommon practice in clinical psychiatry in the management of aggressive events. There seems to be a paucity of evidenced-based research examining the policy framework guiding the use of restraint and seclusion in Asia contexts. The purpose of this study was to conduct an analysis on the guidelines in psychiatric hospitals in Hong Kong, and to explore the extent to which these guidelines were aligned with the international clinical guidelines for the prevention and management of patient aggression in psychiatry. A descriptive document analysis was used to analyse the guidelines from four psychiatric hospitals in Hong Kong in comparison with the NICE (National Institute of Health and Care Excellence UK) guidelines. Data were collected from December 2017 to June 2018. A total of 91 written documents were retrieved. Preventing violence and aggression has the highest level of agreement (31%,) while the use of restrictive interventions has the lowest level of agreement (12%). The sub-recommendation with most in line with the NICE guidelines were restrictive interventions, de-escalation, and improving service users' experiences. However, for example, staff training, working with police, and reduced use of restrictive interventions seemed to have no agreement with the NICE guidelines. Variation exists between the Asian (Hong Kong) local policy framework/guidelines and the European (UK) national policy framework. There are also large discrepancies in the written guidelines on patient aggressive behaviour when comparing local policy frameworks, cluster-based documents, and departmental practices.
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Affiliation(s)
- Tella Lantta
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Jaakko Varpula
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Teris Cheung
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong (SAR), China
| | - Wai Kit Wong
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong (SAR), China
| | - Po Yee Ivy Cheng
- Department of Psychiatry, Pamela Youde Nethersole Eastern Hospital, Hospital Authority, Hong Kong (SAR), China
| | - Tony Ng
- Department of Psychiatry, Pamela Youde Nethersole Eastern Hospital, Hospital Authority, Hong Kong (SAR), China
| | - Chi Fai Ng
- Department of Psychiatry, Tai Po Hospital, Hospital Authority, Hong Kong (SAR), China
| | - Chun Pong Yam
- Department of Psychiatry, Kowloon Hospital, Hospital Authority, Hong Kong (SAR), China
| | - Glendy Ip
- Kwai Chung Hospital, Hospital Authority, Hong Kong (SAR), China
| | - Daniel Bressington
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong (SAR), China
| | - Maritta Välimäki
- Department of Nursing Science, University of Turku, Turku, Finland.,School of Nursing, The Hong Kong Polytechnic University, Hong Kong (SAR), China
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50
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Hawsawi T, Power T, Zugai J, Jackson D. Nurses' and consumers' shared experiences of seclusion and restraint: A qualitative literature review. Int J Ment Health Nurs 2020; 29:831-845. [PMID: 32198811 DOI: 10.1111/inm.12716] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/19/2020] [Accepted: 02/22/2020] [Indexed: 11/28/2022]
Abstract
Seclusion and restraint are coercive practices associated with physical and psychological harm. International bodies have called for an end to these practices. However, these practices continue to be used. Elimination programmes have had some success in reducing the rates of these practices. Understanding coercive practices through the perspectives of involved individuals may facilitate a complete cessation of seclusion and restraint from the practice. Therefore, this qualitative review explored how nurses and consumers experienced seclusion and restraint events in mental health care. Five databases were searched. The search strategy resulted in the inclusion of fourteen qualitative papers. A thematic analysis was used to synthesize the findings. Six themes emerged under three main categories; shared experiences: disruption in care, disruption in the therapeutic relationship and shared negative impacts; nurses' experiences: Absence of less coercive alternatives; and consumers' experiences: overpowered, humiliated and punished. Considering these experiences during planning for seclusion and restraint prevention might facilitate more effective implementation of seclusion and restraint elimination programmes. Our findings suggested that consumers should receive recovery-oriented, trauma-informed and consumer-centred care; while nurses should be better supported through personal, professional and organizational developmental strategies. Further research should focus on investigating shared interventions among consumers and nurses and exploring carers' experiences with coercive practices.
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Affiliation(s)
- Tahani Hawsawi
- Faculty of Nursing, King Abdul-Aziz University, Jeddah, Saudi Arabia
| | - Tamara Power
- Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia
| | - Joel Zugai
- Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia
| | - Debra Jackson
- Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia
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