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

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

Co-designing restrictive practice elimination: A systems thinking approach with mental health service users and practitioners in rural/regional Australia

Elimination of restrictive practices (physical/mechanical restraint and seclusion) from adult acute mental health care services has been demanded internationally for many decades. This study aimed to: (1) Identify priority issues in the elimination of and use of alternative approaches to restrictive practices (seclusion and physical/mechanical restraint) in rural/regional acute adult mental healthcare services, as told by mental healthcare service users and practitioners, (2) identify the community-based, system-level feedback loops that enhance or reduce the use of restrictive practices and viable alternatives and, (3) identify potential action areas to improve system structures to increase regional mental healthcare services' ability to eliminate restrictive practices and use alternative approaches. Group model building (GMB) workshops were held with a small group (n = 9) of mental healthcare practitioners and service users with lived experience of restrictive practice use. This participatory approach enables exploration and visual mapping of local structures causing behaviour patterns of practitioner and service user concern over time - in this case, the barriers, and enablers to alternative approaches to restrictive practices in adult acute mental healthcare services within the Geelong-Barwon region. This is the first study that specifically applies GMB in the discussion of the elimination of restrictive practices in mental health in the non-metropolitan regional/rural context. Participants identified four key priorities in relation to eliminating restrictive practices: (1) self-advocacy, (2) continuity of care, (3) early intervention, and (4) safety for all. The study findings were distilled into a novel preliminary set of mental healthcare practitioner and service user action ideas.

OPCAT: How an international treaty regarding torture is relevant to the Australian mental health system

The United Nations Subcommittee on the Prevention of Torture visits signatory nations to the Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT). Its role is to monitor and support signatory nations in implementing and complying with the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (CAT). In October 2022, the United Nations Subcommittee on the Prevention of Torture visited Australia but was barred from visiting mental health wards in Queensland and all detention facilities in New South Wales leading to the termination of its visit. This breach of Australia's obligations under the OPCAT presents a significant setback for the rights of people with mental illness and other involuntarily detained populations. This piece sets out to demonstrate the relevance of OPCAT to the mental health system in Australia. Individuals who are detained for compulsory treatment in locked facilities such as acute psychiatric inpatient wards and forensic mental health facilities are deprived of their liberty, often out of public view. Thus, it highlights the ethical and professional obligations of all mental health professionals, especially psychiatrists, to safeguard the human rights of individuals being detained in mental health facilities as enshrined in Australia's international legal obligations under the OPCAT. Adhering to these obligations diminishes the risk of future human rights violations of people with mental illness.

Staff responses to interventions aiming to reduce mechanical restraint in adult mental health inpatient settings: a questionnaire-based survey

PURPOSE

To explore mental health staff's responses towards interventions designed to reduce the use of mechanical restraint (MR) in adult mental health inpatient settings.

METHODS

We conducted a cross-sectional, questionnaire-based survey. The questionnaire, made available online via REDCap, presented 20 interventions designed to reduce MR use. Participants were asked to rate and rank the interventions based on their viewpoints regarding the relevance and importance of each intervention.

RESULTS

A total of 128 mental health staff members from general and forensic mental health inpatient units across the Mental Health Services in the Region of Southern Denmark completed the questionnaire (response rate = 21.3%). A total of 90.8% of the ratings scored either 'agree' (45.2%) or 'strongly agree' (45.6%) concerning the relevance of the interventions in reducing MR use. Overall and in the divided analysis, interventions labelled as 'building relationship' and 'patient-related knowledge' claimed high scores in the staff's rankings of the interventions' importance concerning implementation. Conversely, interventions like 'carers' and 'standardised assessments' received low scores.

CONCLUSIONS

The staff generally considered that the interventions were relevant. Importance rankings were consistent across the divisions chosen, with a range of variance and dispersion being recorded among certain groups.

A Pioneer Tool to Reduce Restrictive Practices toward People with Intellectual and Developmental Disabilities

Reducing restrictive practices toward individuals with intellectual and developmental disabilities is a globally recognized imperative and human rights priority. This paper presents a novel tool called LibRe for assessing and reducing restrictive practices. This tool involved an instrumental multistage design and collaboration between professionals, individuals with disabilities, family members, and experts from different fields. It addresses diverse restrictive practices in five key domains: physical or mechanical, chemical or pharmacological, structural, relational, and practices related to contexts and supports. It addresses practices that are pertinent to the Spanish context and that existing tools have not covered. Embedded as a step within an organizational approach, LibRe fosters organizational transformation and provides resources to achieve outcomes within reduction plans for restrictive practices. In total, 156 teams comprising 585 professionals, 64 people with disabilities, and 44 family members responded to the tool. In terms of evidence for internal structure validity, the oblique five-factor model exhibited an adequate fit through confirmatory factor analysis, along with satisfactory reliability indices, according to ordinal alpha and omega. Users positively appraised the tool's usefulness and identified its strengths and challenges. Although further research is needed, preliminary evidence frames LibRe as a useful resource for practice and research.

The importance of individualised care, good communication and trust for reducing nasogastric tube feeding under physical restraint: qualitative multi-informant study

BACKGROUND

Nasogastric tube (NGT) feeding against a patient's consent is an intervention that clinicians working in specialist mental health in-patient units may need to implement from time to time. Little research has explored clinician, patient and carer perspectives on good practice.

AIMS

To use qualitative data from people with lived experience (PWLE), parents/carers and clinicians, to identify components of best practice when this intervention is required.

METHOD

PWLE and parents/carers were recruited via BEAT UK's eating disorder charity. Clinicians were recruited via a post on The British Eating Disorders Society's research page. Semi-structured interviews were administered, transcribed and thematically analysed.

RESULTS

Thirty-six interviews took place and overlapping themes were identified. Participants spoke in relation to three themes: first, the significance of individualised care; second, the importance of communication; third, the impact of staff relationships. Sub-themes were identified and explored.

CONCLUSIONS

Good care evolved around positive staff relationships and individualised care planning rather than standard processes. The centrality of trust as an important mediator of outcome was identified, and this should be acknowledged in any service that delivers this intervention.

Variation in opinions on coercion use among mental healthcare professionals: a questionnaire study

INTRODUCTION

Even if coercive measures are widely applied in psychiatry and have numerous well-known drawbacks, there is limited known on the agreement among mental healthcare professionals' opinions on their use. In a questionnaire study using standardized scenarios, we investigated variation in staff opinions on coercion.

METHODS

In a web-based survey distributed to staff at three psychiatry hospitals, respondents were asked to consider if and what coercion to use by introducing two hypothetical scenarios involving involuntary psychiatric admission and in-hospital coercion.

RESULTS

One hundred thirty-two out of 601 invited staff members responded to the survey (Response Rate = 22%). There was large variation in participating staff members' opinions on how to best manage critical situations and what coercive measures were warranted. In the first scenario, 57% of respondents (n = 76) believed that the patient should be involuntarily admitted to hospital while the remaining respondents believed that the situation should be managed otherwise. Regarding the second scenario, 62% of respondents responded that some in-hospital coercion should be used. The majority of respondents believed that colleagues would behave similarly (60%) or with a tendency towards more coercion use (34%). Male gender, being nursing staff and having less coercion experience predicted being less inclined to choose involuntary hospital admission.

CONCLUSION

There is a high degree of variation in coercion use. This study suggests that this variation persists despite staff members being confronted with the same standardized situations. There is a need for evidence-based further guidance to minimize coercion in critical mental healthcare situations.

Art therapy is associated with a reduction in restrictive practices on an inpatient child and adolescent mental health unit

BACKGROUND

The elimination of restrictive practices, such as seclusion and restraint, is a major aim of mental health services globally. The role of art therapy, a predominantly non-verbal mode of creative expression, is under-explored in this context. This research aimed to determine whether art therapy service provision was associated with a reduction in restrictive practices on an acute inpatient child and adolescent mental health services (CAMHS) unit.

METHODS

The rate (events per 1,000 occupied bed days), frequency (percent of admitted care episodes with incident), duration, and number of incidents of restrictive practices occurring between July 2015 and December 2021 were analysed relative to art therapy service provision. The rate, frequency and number of incidents of intramuscular injected (IM) sedation, oral PRN (as-needed medication) use, and absconding incidents occurring in conjunction with an episode of seclusion or restraint were also analysed.

RESULTS

The rate, frequency, duration, and total number of incidents of seclusion, the frequency and total number of incidents of physical restraint, and the rate, frequency and total number of incidents of IM sedation showed a statistically significant reduction during phases of art therapy service provision.

CONCLUSIONS

Art therapy service provision is associated with a reduction in restrictive practices in inpatient CAMHS.

Nasogastric tube feeding under physical restraint: comprehensive audit and case series across in-patient mental health units in England

AIMS AND METHOD

To identify the clinical characteristics of patients receiving nasogastric tube (NGT) feeding under physical restraint. Clinicians participated via professional networks and subsequent telephone contact. In addition to completing a survey, participants were invited to submit up to ten case studies.

RESULTS

The survey response rate from in-patient units was 100% and 143 case studies were submitted. An estimated 622 patients received NGT feeding under restraint in England in 2020-2021. The most common diagnosis was anorexia nervosa (68.5-75.7%), with depression, anxiety and autism spectrum disorder the most frequent comorbidities. Patients receiving the intervention ranged from 11 to 60 years in age (mean 19.02 years). There was wide variation in duration of use, from once to daily for 312 weeks (mode 1 week; mean 29.1 weeks, s.d. = 50.8 weeks).

CLINICAL IMPLICATIONS

NGT feeding under restraint is not uncommon in England, with variation in implementation. Further research is needed to understand how the high comorbidity and complexity contribute to initiation and termination of the intervention.

Nasogastric tube feeding under restraint: understanding the impact and improving care

BACKGROUND

Nasogastric tube feeding under physical restraint is an intervention that clinicians working in specialist mental health in-patient units may need to implement.

AIMS

To examine the impact of this intervention on people with lived experience, carers and staff.

METHOD

People with lived experience and parents and/or carers were recruited via UK eating disorder charity Beat. Clinicians were recruited via the British Eating Disorders Society's research forum. Qualitative semi-structured interviews were conducted and transcribed, and the results were thematically analysed.

RESULTS

Thirty-six participants took part, and overlapping themes were identified. All participants spoke in relation to four themes: (a) the short-term impact on the patient; (b) the impact on those around the patient; (c) the long-term impact; and (d) the positive impact. Subthemes were identified and explored.

CONCLUSION

This lifesaving intervention can also negatively affect patients, parents and carers, peers and staff. Further research is needed to understand how interactions and environmental modifications can mitigate the negative impacts.

Examining the need for a high level of therapeutic security at a regional forensic mental health service in Aotearoa New Zealand

The ceiling of therapeutic security in Aotearoa New Zealand is medium security. The aim of this study is to identify and characterise a putative cohort of high-secure patients at a medium-secure regional forensic mental health service. A retrospective review of all admissions to a specific service was conducted over 3.75 years. The Dangerousness Understanding, Recovery and Urgency Manual, Triage Security Scale (DUNDRUM-1) was used to identify patients with high-secure care needs. A multiple logistic regression analysis was used to identify the local needs of this cohort. We found a significant incidence (an admission every 55 days) and prevalence (11%) of mixed-gendered and culturally diverse patients with high-secure care needs. The cohort had a high prevalence of psychosis and violent offences, and relatively short length of stay. There is also an indication that the cohort was subject to more restrictive practice. A solution is proposed to meet the needs of this cohort.

Staff responses to self-harm by children and young people in mental health inpatient settings: Experiences and views of children and young people, parents and staff

This study aimed to understand the views of children and young people (CYP), parents and staff on how staff should respond to incidents of self-harm carried out by CYP in mental health inpatient settings. Semi-structured interviews were conducted with CYP (n = 6), parents (n = 5) and mental health professionals (n = 6) with experience of this issue. Data were analysed using reflexive thematic analysis. Two superordinate themes were identified: (1) The threshold for intervening; and (2) Interpersonal attributes of staff. There was general agreement among participants about the interpersonal skills that staff should possess to work safely and effectively with this population. There was disagreement between staff and parent participants about the appropriate threshold for using restrictive interventions to manage incidents of self-harm for this group. Our findings suggest that further work is needed to develop effective approaches for addressing self-harm in this population which are considered acceptable to all key stakeholders. The results of this study could be used to inform future intervention development.

Restrictive Practices and the 'Need' for Positive Behaviour Support (PBS): A Critical Discourse Examination of Disability Policy Beliefs

BACKGROUND

Few studies have considered policies which underpin the promotion of positive behaviour support (PBS). The present study examined policy beliefs about PBS and their relationship to restrictive practices.

METHODS

Discourse network analysis (a combination of critical discourse analysis and social network analysis) was used.

RESULTS

A total of 11 policies were examined from which 38 belief statements were coded. One cluster was identified which promoted 13 dominant beliefs. Dominant discourses related to law, safety and the environment were evident. A conceptual representation of the shared PBS beliefs demonstrated contradictions in PBS policy.

CONCLUSIONS

There is evidence that PBS policies have become informal rules for using restrictive practices, not reducing them. They are also acting as surrogates to debate conflicts between political, personal and bureaucratic interests. Three recommendations for improved PBS policy are provided.

'Stakeholders are almost always resistant': Australian behaviour support practitioners' perceptions of the barriers and enablers to reducing restrictive practices

A restrictive practice (RP) is defined as a practice or intervention that has the effect of restricting the rights or freedom of movement of a person, and includes physical, mechanical, and chemical restraint, and seclusion. If misused or overused, RPs may present serious human rights infringements. In Australia, behaviour support practitioners who deliver behaviour support funded by the National Disability Insurance Scheme are responsible for developing positive behaviour support plans that aim to reduce and eliminate the use of RPs. At present, little is known about the barriers that behaviour support practitioners experience when attempting to reduce and eliminate the use of RPs and, conversely, what helps (or enables) them to reduce and eliminate RPs. To learn more, we conducted an online survey consisting of two open-ended questions with 109 Australian behaviour support practitioners to identify barriers and enablers. We found that fear and reluctance on the part of stakeholders were often barriers to reducing the use of RPs. However, we found that having time, funding, and resources for training, supervision, other implementation activities, care team collaboration, and data-based decision-making helped overcome barriers. We provide specific recommendations for addressing identified barriers for individual behaviour support practitioners, service provider organisations, and government and regulatory agencies.

Decision-making and best practice when nasogastric tube feeding under restraint: multi-informant qualitative study

BACKGROUND

Clinicians working in mental health in-patient settings may have to use nasogastric tube feeding under physical restraint to reverse the life-threatening consequences of malnutrition when this is driven by a psychiatric condition such as a restrictive eating disorder.

AIMS

To understand the decision-making process when nasogastric tube feeding under restraint is initiated in mental health in-patient settings.

METHOD

People with lived experience of nasogastric tube feeding under restraint and parents/carers were recruited via the website of the UK's eating disorder charity BEAT. Eating disorder clinicians were recruited via an online post by the British Eating Disorders Society. Semi-structured interviews were administered to all participants.

RESULTS

Themes overlapped between the participant groups and were integrated in the final analysis. Two main themes were generated: first, 'quick decisions', with the subthemes of 'medical risk', 'impact of not eating' and 'limited discussions'; second, 'slow decisions', with subthemes of 'threats', 'discussions with patient', 'not giving up' and 'advanced directives'. Benefits and harms of both quick and slow decisions were identified.

CONCLUSIONS

This research offers a new perspective regarding how clinical teams can make best practice decisions regarding initiating nasogastric feeding under restraint. In-patient mental health teams facilitating this clinical intervention should consider discussing it with the patient at the beginning of their admission in anticipation of the need for emergency intervention and in full collaboration with the multidisciplinary team.

Mapping review of interventions to reduce the use of restrictive practices in children and young people's institutional settings: The CONTRAST study

Restrictive practices are often used harmfully with children in institutional settings. Interventions to reduce their use do not appear to have been mapped systematically. Using environmental scanning, we conducted a broad-scope mapping review of English language academic databases, websites and social media, using systematic methods. Included records (N = 121) were mostly from the United States and contained details of 82 different interventions. Children's participation was limited. Reporting quality was inconsistent, which undermined claims of effectiveness. Overall, despite a multitude of interventions, evidence is limited. Leaders should consider the evidence, including children's perspectives, before introducing poorly understood interventions into children's settings.

Incidence and type of restrictive practice use in residential disability facilities in Ireland, a cross-sectional study

Restrictive practices (RPs) are a contentious issue in health and social care services. While use may be warranted in some instances, there are risks and concerns around human rights infringements. There are limited data available on the types and incidences of RPs used in health and social care services internationally. The objective of this study is to describe the type of RPs and incidence of use in disability residential care facilities (RCFs) in Ireland. RP notifications from disability RCFs reported from November 2019 to October 2020 were extracted from the Database of Statutory Notifications from Social Care in Ireland. National frequency and incidence of use of categories and type of RPs were calculated. The number and percentage of disability RCFs reporting RP use, along with the mean annual incidence of use, were also calculated. A total of 48,877 uses of RPs were notified from 1387 disability RCFs (9487 beds) during the 12-month period. The national incidence of RPs use per 1000 beds was as follows: all categories: 5152.0, environmental: 2988.2, physical: 1403.0, other: 527.0 and chemical: 233.8. The most frequently used RPs for each category was as follows: environmental: door locks, physical: other physical, other: liberty and autonomy and chemical: anxiolytics. Most RCFs (81.7%) reported at least one RPs use. The median incidence of any RPs per 1000 beds in these RCFs was 4.75 (IQR: 2.00 to 51.66). Usage of RPs was generally low, although some RCFs reported relatively high usage. Nationally, on average, five RPs were applied per resident over 12 months; environmental contributing to more than half. These findings can be used to inform policy, measure progress in reducing RPs use and for cross-jurisdiction comparisons.

Patients' and staff members' experiences of restrictive practices in acute mental health in-patient settings: systematic review and thematic synthesis

BACKGROUND

Recent guidance has called for the reduction of restrictive practice use owing to growing concerns over the harmful physical and psychological effects for both patients and staff. Despite concerns and efforts, these measures continue to be used regularly to manage challenging behaviour in psychiatric in-patient settings.

AIMS

To undertake a systematic review of patients' and staff members' experiences of restrictive practices in acute psychiatric in-patient settings.

METHOD

A systematic review and thematic synthesis was conducted using data from 21 qualitative papers identified from a systematic search across three electronic databases (PsycInfo, Embase and MEDLINE) and citation searching. The protocol for the review was pre-registered on PROSPERO (CRD42020176859). The quality of included papers was examined using the Critical Appraisal Skills Programme (CASP).

RESULTS

Four overarching themes emerged from the experiences of patients: the psychological effects, staff communication, loss of human rights and making changes. Likewise, the analysis of staff data produced four themes: the need for restrictive practices, the psychological impact, decision-making and making changes. Patient and staff experiences of restrictive practices were overwhelmingly negative, and their use carried harmful physical and psychological consequences. Lack of support following restraint events was a problem for both groups.

CONCLUSIONS

Future programmes seeking to improve or reduce restrictive practices should consider the provision of staff training covering behaviour management and de-escalation techniques, offering psychological support to both patients and staff, the importance of effective staff-patient communication and the availability of alternatives.

Non-restrictive interventions to reduce self-harm amongst children in mental health inpatient settings: Systematic review and narrative synthesis

Rates of self-harm amongst children appear to be increasing. This presents challenges for practitioners responsible for maintaining the safety of children admitted to mental health inpatient settings. Policy guidelines recommend that practitioners should aim to avoid the use of restrictive practices for children. It is currently unclear, however, what evidence-based alternatives to restrictive practices are available. We aimed to identify what non-restrictive interventions have been proposed to reduce self-harm amongst children in mental health inpatient settings and to evaluate the evidence supporting their use in clinical practice. A systematic search of five databases (CINAHL, Embase, Ovid MEDLINE, APA Psycinfo, and Cochrane) was conducted to identify articles reporting on non-restrictive interventions aimed at reducing self-harm amongst children in mental health inpatient settings. Articles were quality assessed and relevant data were extracted and synthesized using narrative synthesis. Searches identified relatively few relevant articles (n = 7) and these were generally of low methodological quality. The underlying theoretical assumptions and putative mechanisms of change for the interventions described were often unclear. Despite concerns about the rates of self-harm amongst children in mental health inpatient settings, there is a lack of high-quality research to inform clinical practice. There is an urgent need to develop effective non-restrictive interventions aimed at reducing self-harm for children using inpatient mental health services. Intervention development should be theoretically informed and be conducted in collaboration with people who have lived experience of this issue.

Contextual Barriers and Enablers to Safewards Implementation in Victoria, Australia: Application of the Consolidated Framework for Implementation Research

Background: Safewards is a complex psychosocial intervention designed to reduce conflict and containment on inpatient mental health units. There is mounting international evidence of the effectiveness and acceptability of Safewards. However, a significant challenge exists in promising interventions, such as Safewards, being translated into routine practice. The Consolidated Framework for Implementation Research (CFIR) provides a framework through which to understand implementation in complex health service environments. The aim was to inform more effective implementation of Safewards using the CFIR domains and constructs, capitalizing on developing an understanding of variations across wards. Method: Seven Safewards Leads completed the Training and Implementation Diary for 18 wards that opted in to a trial of Safewards. Fidelity Checklist scores were used to categorize low, medium and high implementers of Safewards at the end of the 12-week implementation period. Results: Qualitative data from the diaries were analyzed thematically and coded according to the five CFIR domains which included 39 constructs. Twenty-six constructs across the five domains were highlighted within the data to have acted as a barrier or enabler. Further analysis revealed that six constructs distinguished between low, medium, and high implementing wards. Discussion: Our findings suggest that for implementation of Safewards to succeed, particular attention needs to be paid to engagement of key staff including managers, making training a priority for all ward staff, adequate planning of the process of implementation and creating an environment on each inpatient unit that prioritize and enables Safewards interventions to be undertaken by staff regularly.

The relationship between ethnic background and the use of restrictive practices to manage incidents of violence or aggression in psychiatric inpatient settings

Restrictive practices raise considerable concern in mental health inpatient care. Previous studies suggest there are disparities in the use of restrictive practices to manage service users of different ethnic groups. The present study analyses the relationship between ethnicity and the use of restrictive practices to manage incidents of violence or aggression in inpatient settings across an NHS Mental Health Trust. Three years' worth of routinely collected incident data were analysed using multilevel multiple logistic regression to assess the relationship between ethnic group and four types of restrictive practices: physical restraint (without prone), physical restraint (with prone), seclusion, and rapid tranquilization. We controlled for a range of demographic variables and the type and severity of the incident. Adjusted analyses showed that service users with a Black African [Odds Ratio = 1.96, 95% CI: 1.36-2.83, P < 0.001], Black Caribbean [Odds Ratio = 1.76, 95% CI: 1.08-2.85, P = 0.022], Black Other [Odds Ratio = 1.76, 95% CI: 1.27-2.44, P = 0.001], and Mixed [Odds Ratio = 1.88, 95% CI: 1.11-3.18, P = 0.019] ethnic background were more likely to be secluded, and Black Caribbean [Odds Ratio = 1.45, 95% CI: 1.02-2.07, P = 0.040] service users were more likely to be restrained in prone position. We did not detect differences in the use of physical restraints without prone or in the use of rapid tranquilization. Our findings illustrate the need to focus on outcomes for different ethnic groups when implementing restraint reduction programmes.

Benchmarking to reduce restrictive practices in forensic mental health services: a Delphi study

OBJECTIVES

Forensic mental health services (FMHS) have higher rates, duration and frequency of restrictive practices (seclusion, physical restraint and mechanical restraint). Data generated by services can be used to set targets (benchmarks) with like services to reduce or eliminate restrictive practices. The aim of this study was to develop restrictive practice benchmarks for Australian and New Zealand FMHS.

METHOD

A participatory action research methodology was used by conducting a Delphi study. FMHS experts provided de-identified service-specific restrictive practice data, which was used to stimulate reflection towards the development of restrictive practice benchmarks.

RESULTS

Consensus decision-making was reached on benchmarks for the rate, duration and frequency of seclusion and physical restraint. Mechanical restraint was found to be a rare event, requiring event specific review in each service.

CONCLUSIONS

Benchmarking with FMHS may assist in working to reduce restrictive practices and encourage the scrutiny of service practice. Establishment of a FMHS network might assist to embed the proposed benchmarks.

Gender, Trauma and the Regulation of the Use of Restraint on Women in Australian Mental Health Services

The use of physical, mechanical and/or chemical restraint is authorised by mental health legislation in most Australian jurisdictions. Research indicates that women have different experiences and needs in relation to the use of restraint, but legislation does not mention sex or gender as relevant considerations in the authorisation, use or monitoring of these practices. This is especially problematic in light of the potential for restraint use to traumatise, or retraumatise, women service users. This section discusses the treatment of gender- and trauma-related considerations in Australian mental health legislation and supporting policy, pointing to several gaps and proposing appropriate changes to practice and regulation.

Chemical restraint of adults with intellectual disability and challenging behaviour in Queensland, Australia: Views of statutory decision makers

BACKGROUND

Psychotropic medication is widely prescribed to treat mental illness. However, it is controversial when used as a chemical restraint (CR) to manage challenging behaviours (CBs) of adults with intellectual disability (ID). CR has potentially negative consequences and affects human rights.

METHOD

Qualitative research conducted between 2014 and 2015 explored the views of 'guardian' decision makers appointed under unique Queensland legislation oversighting the use of CR.

RESULTS

Findings included (1) negative conceptualization of CR, (2) concerning relationships with prescribers and disability sector staff, (3) challenges to information seeking about people with ID prescribed CR and (4) problematic implementation of positive behaviour support plans.

CONCLUSION

According to guardians, CR may be used in lieu of community supports, and prescribers sometimes diagnose mental illness to avoid CR legislative requirements. Guardians, prescribers and professionals would benefit from training that addresses the intersection between physical and mental health, CB and CR.

The use of positive behaviour support plans in mental health inpatient care: A mixed methods study

WHAT IS KNOWN ON THE SUBJECT?: There is a drive to use positive and proactive approaches to mental health care to reduce the use of restrictive practices such as seclusion and restraint. Positive behaviour support plans have been used successfully to do this in learning disability services, and in England, it is now a regulatory requirement that anyone with challenging behaviour should have an individualized behaviour support plan. However, positive behaviour support plans specifically have not been evaluated as part of routine mental health care and mental health nurses' and relatives' attitudes towards them are unknown. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This evaluation of positive behaviour support plans in routine mental health inpatient care found that they had not been widely implemented or completed as intended. Barriers to the use of the plans included confusion among nurses and relatives around the principles of positive behaviour support, including how, when and for whom the plans should be used, difficulties in being able to describe the function of a patient's behaviour and lack of engagement with relatives and patients. Nevertheless, nurses and relatives valued the plans, in particular for their potential to facilitate holistic care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: To use the plans successfully, mental health nurses will need training to understand fully the rationale behind the positive behaviour support approach and will need to engage more with relatives and patients. Commitment to the approach from the whole care team and organization will be needed to implement the plans consistently for all patients. Abstract Introduction An international drive is to minimize restrictive practices in mental health care. Positive behaviour support plans (PBSPs) help staff prevent behaviour which would require restrictive intervention. Originating in learning disability services, data within mental health care are limited. Aims To evaluate PBSPs within a mental health inpatient service; understand mental health nurses' and relatives' attitudes to them; and understand the barriers and facilitators for their use in routine mental health care. Methods Mixed methods-quality ratings and interviews with relatives and nurses. Results Positive behaviour support plans were poorly implemented. Relatives and nurses valued the potential of PBSPs to facilitate holistic care, though no relative had contributed to one and not every eligible patient had one. Barriers to their use included confusion around positive behaviour support, including how, when and for whom PBSPs should be used, and difficulties describing the function of a behaviour. Discussion The potential of PBSPs to improve mental health care is recognized. However, there are barriers to their use which should be addressed to ensure that PBSPs have been properly implemented before their impact on patient care can be assessed. Implications for practice Mental health professionals implementing PBSPs should engage with relatives and patients, gain organizational commitment and ensure that those involved understand fully the positive behaviour support approach.

Promoting positive and safe care in forensic mental health inpatient settings: Evaluating critical factors that assist nurses to reduce the use of restrictive practices

Reducing and eliminating the use of restrictive practices, such as seclusion and restraint, is a national priority for Australia's mental health services. Whilst legislation, organization and practice changes have all contributed to a reduction in these practices, forensic mental health services continue to report high rates. This paper details the findings of research that examined the experiences of nurses working in the inpatient forensic mental health setting. The research aimed to (i) document the experiences of nurses working in the forensic mental health setting, (ii) articulate their perceived unique skill set to manage challenging patient behaviours, and (iii) determine how their experiences and skill set can inform practice changes to reduce the use of restrictive practices. Thirty-two nurses were recruited from one Australian forensic mental health service. Data were collected using semi-structured interviews and analysed using inductive content analysis. Four categories were identified that influenced practice experiences: (i) working in a challenging but interesting environment, (ii) specialty expertize, (iii) exposure to aggression and resilience as a protective factor, and (iv) the importance of effective teamwork and leadership. Forensic mental health care is complex, highly specialized, and often delivered in an unpredictable environment. Whilst high rates of restrictive practices may be linked to the unique characteristics of forensic patients, training, teamwork, and leadership are critical factors influencing their use in this setting. Nurses working in this area need to be educated and supported to work confidently and safely with this high-risk patient cohort.

Safewards Impact in Inpatient Mental Health Units in Victoria, Australia: Staff Perspectives

Introduction: Mental health professionals working in acute inpatient mental health wards are involved in a complex interplay between an espoused commitment by government and organizational policy to be recovery-oriented and a persistent culture of risk management and tolerance of restrictive practices. This tension is overlain on their own professional drive to deliver person-centered care and the challenging environment of inpatient wards. Safewards is designed to reduce conflict and containment through the implementation of 10 interventions that serve to improve the relationship between staff and consumers. The aim of the current study was to understand the impact of Safewards from the perspectives of the staff. Methods: One hundred and three staff from 14 inpatient mental health wards completed a survey 12 months after the implementation of Safewards. Staff represented four service settings: adolescent, adult, and aged acute and secure extended care units. Results: Quantitative results from the survey indicate that staff believed there to be a reduction in physical and verbal aggression since the introduction of Safewards. Staff were more positive about being part of the ward and felt safer and more connected with consumers. Qualitative data highlight four key themes regarding the model and interventions: structured and relevant; conflict prevention and reducing restrictive practices; ward culture change; and promotes recovery principles. Discussion: This study found that from the perspective of staff, Safewards contributes to a reduction in conflict events and is an acceptable practice change intervention. Staff perspectives concur with those of consumers regarding an equalizing of staff consumer relationships and the promotion of more recovery-oriented care in acute inpatient mental health services.

Alternatives to Compulsory Detention and Treatment and Coercive Practices in Mental Health Settings

Informed consent to medical treatment is generally presumed to be central to the provision of good quality health care. Despite this presumption, legislation exists in many countries that enables the compulsory detention and treatment of people with severe mental health conditions regardless of their wishes. This column discusses global efforts to reduce, prevent and end compulsory detention, treatment and coercive practices in mental health and community settings. It summarises the current state of research, identifying overarching themes in the search for effective non-coercive practices, before focusing on hospital and community-based initiatives.

Nurses' attitudes towards the use of PRN psychotropic medications in acute and forensic mental health settings

Many countries now have national mental health policies and guidelines to decrease or eliminate the use of seclusion and restraint yet the use of Pro Re Nata (PRN) medications has received less practice evaluation. This research aimed to identify mental health nurses' attitudes towards the use of PRN medications with mental health consumers. Participants were working in forensic mental health and non-forensic acute mental health settings. The "Attitudes towards PRN medication use survey" was used and data were collected online. Data were analysed using the Statistical Package Social Sciences, Version 22.0. Practice differences between forensic and other acute mental health settings were identified related to the use of PRN medications to manage symptoms from nicotine, alcohol and other drug withdrawal. Differences related to the useage of comfort rooms and conducting comprehensive assessments of consumers' psychiatric symptoms were also detected. Qualitative findings highlighted the need for increased accountability for the prescribing and administration of PRN medications along with more nursing education/training to use alternative first line interventions. Nurses administering PRN medications should be vigilant regarding the indications for this practice to ensure they are facilitating the consumer's recovery by reducing the use of all forms of potentially restrictive practices in the hospital setting. The reasons for using PRN medications and PRN administration rates must be continually monitored to avoid practices such as high dose antipsychotics use and antipsychotic polypharmacy to ensure the efficacy of the consumers' management plans on their health care outcomes.

Patient perspectives on barriers and enablers to the use and effectiveness of de-escalation techniques for the management of violence and aggression in mental health settings

AIM

Investigate patient perspectives on barriers and enablers to the use and effectiveness of de-escalation techniques for aggression in mental health settings.

BACKGROUND

De-escalation techniques are the recommended first-line intervention for the management of aggression in mental health settings internationally, yet use of higher risk restrictive practices persists. This indicates de-escalation techniques are not used at optimum frequency and/or there are important factors limiting their use and effect.

DESIGN

Descriptive qualitative research using semi-structured interviews and Framework Analysis.

METHODS

Inpatient interviews (N = 26) exploring staff, patient and environmental factors influencing the use and effectiveness of staff de-escalation were conducted mid-2014. Three service user researchers led analysis.

RESULTS

Data were synthesized in three deductive themes relating to staff, patient and environmental influences on the use and effectiveness of de-escalation techniques. The dominant view was that restrictive practices, rather than de-escalation techniques, are used in response to escalating patient behaviour. Under-use of de-escalation techniques was attributed to: lack of staff reflection on culture and practice and a need to retain control/dominance over patients. Ward rules, patient factors and a lack of staff respect for patients diluted their effectiveness. Participants identified a systematic process of de-escalation, rule subversion, reduced social distance and staff authenticity as enablers of effective de-escalation.

CONCLUSION

This study investigated patient perspectives on staff, patient and environmental influences on the use and effectiveness of de-escalation techniques. Our framework of barriers and enablers provides indicators of organizational/behaviour change targets for interventions seeking to reduce violence and restrictive practices through enhanced de-escalation techniques.

Attitudes towards seclusion and restraint in mental health settings: findings from a large, community-based survey of consumers, carers and mental health professionals

AIMS

There are growing calls to reduce, and where possible eliminate, the use of seclusion and restraint in mental health settings, but the attitudes and beliefs of consumers, carers and mental health professionals towards these practices are not well understood. The aim of this study was to compare the attitudes of mental health service consumers, carers and mental health professionals towards seclusion and restraint in mental health settings. In particular, it aimed to explore beliefs regarding whether elimination of seclusion and restraint was desirable and possible.

METHODS

In 2014, an online survey was developed and widely advertised in Australia via the National Mental Health Commission and through mental health networks. The survey adopted a mixed-methods design, including both quantitative and qualitative questions concerning participants' demographic details, the use of seclusion and restraint in practice and their views on strategies for reducing and eliminating these practices.

RESULTS

In total 1150 survey responses were analysed. A large majority of participants believed that seclusion and restraint practices were likely to cause harm, breach human rights, compromise trust and potentially cause or trigger past trauma. Consumers were more likely than professionals to view these practices as harmful. The vast majority of participants believed that it was both desirable and feasible to eliminate mechanical restraint. Many participants, particularly professionals, believed that seclusion and some forms of restraint were likely to produce some benefits, including increasing consumer safety, increasing the safety of staff and others and setting behavioural boundaries.

CONCLUSIONS

There was strong agreement across participant groups that the use of seclusion and restraint is harmful, breaches human rights and compromises the therapeutic relationship and trust between mental health service providers and those who experience these restrictive practices. However, some benefits were also identified, particularly by professionals. Participants had mixed views regarding the feasibility and desirability of eliminating these practices.