Caroline Larue

Factors influencing decisions on seclusion and restraint

Seclusion with or without restraint is a measure for managing aggressive or agitated clients and promoting site security, particularly in an emergency psychiatric setting. The decision to control a potentially dangerous persons behaviour by removal or seclusion seems ethically justifiable in such a setting. However, although the decisions on these restrictive measures are based on rational needs, they are also influenced by the healthcare teams perceptions of the client and by the characteristics of the team and the environment. The purpose of this paper is to set out and categorize the factors in play in aggression- and agitation-management situations as perceived by the healthcare teams, particularly the nurses. The first part of the paper deals briefly with the settings in which control measures are applied in a province in eastern Canada and the effect of such measures on patients and healthcare teams. The second part identifies the factors involved in the management of agitation and aggression behaviour. The final part discusses the current spin-offs from this knowledge as well as promising paths for further research on the factors involved. The ultimate objective is to reduce recourse to coercive measures and enhance professional practices.

Prevalence and correlates of seclusion with or without restraint in a Canadian psychiatric hospital: a 2‐year retrospective audit

Seclusion with or without restraint is a measure used to manage patients with challenging behaviours. Although controversial, the intervention remains poorly documented, especially in Canadian psychiatric hospitals. The purpose of this study is to assess the prevalence of the measure and identify any correlated demographic characteristics and psychiatric disorders. Episodes of seclusion with or without restraint were extracted from a computerized, hospital-based system introduced specifically to track such interventions. Of 2721 patients hospitalized during that time, 23.2% (n = 632) were secluded with or without restraint, and 17.5% (n = 476) were secluded with restraint. Younger age, schizophrenia or other psychosis, bipolar and personality disorder, and longer stay in hospital are predictors of an episode of seclusion with or without restraint. Younger age, bipolar and personality disorders and a longer stay in hospital are predictors of an episode of seclusion with restraint. For patients who spent longer in seclusion and under restraint, there is a positive association with longer stay in hospital. In this inpatient psychiatric facility, seclusion with or without restraint thus appears to be common. More research is warranted to better identify the principal factors associated with seclusion and restraint and help reduce resort to these measures.

The Experience of Seclusion and Restraint in Psychiatric Settings: Perspectives of Patients

Many studies report that the use of seclusion and restraint (SR) is experienced negatively by patients who experience feelings of shame, helplessness, and humiliation, and may relive previous trauma events. Since 2000, in Québec, exceptional measures like SR have been framed by a protocol. This protocol provides health care teams with guidelines for relieving, containing, and reducing the suffering caused by SR. We have no knowledge, however, about the views of patients regarding application of the protocol. This study aims to understand the perception of patients regarding application of the SR protocol. For this purpose, a questionnaire was presented to patients (n = 50) who experienced an episode of SR in a psychiatric hospital in Canada. Results show that patients had a nuanced perception of SR: Some felt that SR was a helpful measure, while others felt that SR was not a helpful measure. Patients tended to agree with statements related to the comfort and safety of seclusion rooms and the meeting of their physical needs. Regarding support, they suggested relational, drug, and environmental interventions to prevent seclusion. Finally, nearly all patients perceived that the health care team did not follow-up with the patients after the experience; such follow-up is essential for reconstructing a sometimes confusing event.

Predictive Validity and Psychiatric Nursing Staff's Perception of the Clinical Usefulness of the French Version of the Dynamic Appraisal of Situational Aggression

This study seeks to evaluate the predictive validity of the French version of the Dynamic Appraisal of Situational Aggression (DASAfr) and psychiatric nurses’ perceptions of the clinical usefulness of the scale. The study was conducted in a 12-bed psychiatric intensive care unit in a large adult general psychiatric hospital. We found that the total score on the DASAfr has acceptable predictive accuracy for aggression against others and against staff and for seclusion with restraints; predictive accuracy was poorer for aggression against objects. Moreover, the nurses though the scale would be useful to their practice; and, indeed, the team still uses the DASAfr.

Nursing Practices Recorded in Reports of Episodes of Seclusion

The purpose of this study is to describe the nursing practices recorded in reports of patient episodes of seclusion, with or without restraints, in a specialized psychiatric facility in Quebec. The reports for all adult patients secluded (n = 4863) in a psychiatric unit between April 1, 2007 and March 31, 2009, were examined. Descriptive analyses were performed. The main reasons for seclusion were agitation, disorganization, and aggressive behaviour. The alternative methods that were attempted included stimulus reduction, extra medication, and working with the patient to find a solution. Few families were notified about their relations seclusion. More hours of seclusion were reported in the evening and at night. Our results are comparable to those obtained by other investigators. Some of the variables have not been the subject of much research: for example, health conditions during seclusion with or without restraint and partnerships with family members. Our findings also suggest that, in their analyses, studies should differentiate between cognitive-impairment and adult-psychiatry units as well as long-term seclusion and short-term seclusion. The information reported by the nurse makes no distinction between short-stay and long-stay adult psychiatric units. Only one psychiatric facility was investigated in this study, precluding generalization.

Post-Seclusion and/or Restraint Review in Psychiatry: A Scoping Review

CONTEXT It has been suggested that after an incident in which a patient has been placed in seclusion or in restraints, an intervention should be conducted after the event to ensure continuity of care and prevent recurrences. Several terms are used, and various models have been suggested for post-seclusion and/or restraint review; however, the intervention has never been precisely defined. OBJECTIVE This article presents a scoping review on post-seclusion and/or restraint review in psychiatry to examine existing models and the theoretical foundations on which they rely. METHOD A scoping review of academic articles (CINAHL and Medline database) yielded 28 articles. RESULTS Post-seclusion and/or restraint review has its origins in the concepts of debriefing in psychology and reflective practice in nursing. We propose a typology in terms of the intervention target, including the patient, the health care providers, or both. IMPLICATIONS The analysis found that the review ought to involve both the patient and the care providers using an approach that fosters reflexivity among all those involved in order to change the practice of seclusion in psychiatric settings. ACCESSIBLE SUMMARY • Established literature documented widely that seclusion and restraint has adverse physical and psychological consequences for patient and for health care providers. • Post-seclusion and/or restraint review is promoted in most guidelines, but there is no scoping or systematic review yet on the subject. • The origins of post-seclusion and/or restraint review are in the concepts of debriefing in psychology and reflective practice in nursing. • We propose that post-seclusion and/or restraint review should focus on both patients and health care providers.• Systematic post-seclusion and/or restraint review should be performed after each event, and its effects on patients and on mental health professionals should be rigorously assessed.

Group Learning Strategies for Nursing Students: Reflections on the Tutor Role

The aim of this article is to propose, first, a typology of the learning strategies that nursing students in the second year of a nursuing baccalaureate program use in PBL group work with a clinical nursing situation; and, second, a typology of tutor interventions during such sessions. Two complete PBL sessions were recorded on video. They were then transcribed, and, using a conceptual model of learning strategies, the data was analyzed with NVivo 7 software. The study shows that it is mainly during the problem-understanding phase that students elaborate and organize knowledge; in the knowledge-application phase they repeat what has already been set down in their concept map rather than engage in activities of elaboration, generalization or discrimination.

Reflective Practice: A Comparative Dimensional Analysis of the Concept in Nursing and Education Studies.

AIM This paper reports on an analysis of the concept of reflective practice. BACKGROUND Reflective practice, a concept borrowed from the field of education, is widely used in nursing. However, to date, no study has explored whether this appropriation has resulted in a definition of the concept specific to the nursing discipline. DATA SOURCES A sample comprised of 42 articles in the field of nursing drawn from the CINAHL database and 35 articles in education from the ERIC database (1989-2013) was analyzed. REVIEW METHOD A concept analysis using the method proposed by Bowers and Schatzman was conducted to explore the differing meanings of reflective practice in nursing and education. RESULTS In nursing, the dimensions of the concept differ depending on context. In the clinical context, the dimensions may be summarized as theory-practice gap, development, and caring; in training, as learning, guided process, and development; and in research, as knowledge, method, and social change. In education, the concept is also used in the contexts of training (the dimensions being development, deliberate review, emotions, and evaluation) and research (knowledge, temporal distance, and method). The humanist dimension in nursing thus reflects a use of the concept more specific to the discipline. CONCLUSION The concept analysis helped clarify the meaning of reflective practice in nursing and its specific use in the discipline. This observation leads to a consideration of how the concept has developed since its appropriation by nursing; the adoption of a terminology particular to nursing may well be worth contemplating.

Profiles of patients admitted to a psychiatric intensive care unit: secluded with or without restraint.

Objective: To identify and describe the profiles of patients admitted to a psychiatric intensive care unit (PICU) as they relate to seclusion and restraint. Method: Multiple correspondence analysis (MCA) and cluster analysis were performed with data for 114 patients admitted to a PICU from June 8, 2010, to June 7, 2011. Results: The MCA revealed that the presence or absence of seclusion and restraint was the main factor explaining the variance. Admitted patients fall into 5 profiles, 2 of which are significantly associated with seclusion and restraint: young psychotic men and women with bipolar disorder. Conclusions: The differentiation of patient profiles as they relate to seclusion and restraint should lead to the development of profile-specific interventions before, during, and after seclusion and restraint.

Identification and Analysis of Factors Contributing to the Reduction in Seclusion and Restraint for a Population with Intellectual Disability.

BACKGROUND A cohort of 11 patients with an intellectual disability and a psychiatric diagnosis present severe behavioural disorders in psychiatric hospital of Quebec in 2009. Control-measure use for this clientele has now been reduced. How do management personnel, families and care teams explain the changes? What clinical interventions did management and care providers implement that contributed to the reduction? METHOD A retrospective case study was conducted. Five focus groups were held with people involved in their care, and the patient files were examined. RESULTS The factors contributing to this change were the cohesion of the care providers, the involvement of the families and the efforts to determine the function of the behaviour. IMPLICATIONS This study may inspire other care teams to try new approaches in dealing with patients with severe behavioural disorders. Also, the model of factors and interventions supporting a reduction in seclusion and restraint measures may inspire future studies.