Richard Whittington

Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends

ObjectiveThe aim of this study was to identify quantitative data on the use of seclusion and restraint in different countries and on initiatives to reduce these interventions.MethodsCombined literature review on initiatives to reduce seclusion and restraint, and epidemiological data on the frequency and means of use in the 21st century in different countries. Unpublished study was detected by contacting authors of conference presentations. Minimum requirements for the inclusion of data were reporting the incidence of coercive measures in complete hospital populations for defined periods and related to defined catchment areas.ResultsThere are initiatives to gather data and to develop new clinical practice in several countries. However, data on the use of seclusion and restraint are scarcely available so far. Data fulfilling the inclusion criteria could be detected from 12 different countries, covering single or multiple hospitals in most counties and complete national figures for two countries (Norway, Finland). Both mechanical restraint and seclusion are forbidden in some countries for ethical reasons. Available data suggest that there are huge differences in the percentage of patients subject to and the duration of coercive interventions between countries.ConclusionsDatabases on the use of seclusion and restraint should be established using comparable key indicators. Comparisons between countries and different practices can help to overcome prejudice and improve clinical practice.

Anxiety, burnout and coping styles in general hospital staff exposed to workplace aggression: A cyclical model of burnout and vulnerability to aggression

Although an increasing problem, the aggression ( physical assault, threatening behaviour and verbal aggression) directed toward general hospital staff rather than staff in psychiatric institutions has not been widely investigated. The present study first compared anxiety, coping styles and burnout according to the frequency of aggressive experiences. Second, a sub-sample was examined to determine any immediate after-effects from aggressive encounters. Healthcare staff ( n = 375) across professions completed the State-Trait Anxiety Inventory, the Maslach Burnout Inventory and the Coping Responses Inventory, which were analysed according to the type and frequency of aggression experienced within the preceding year. There were no significant differences in levels of anxiety or in coping styles. However, significant differences were determined in levels of burnout. Emotional exhaustion and depersonalization were significantly higher in those staff more frequently victimized suggesting that aggressive encounters might lead to an increase in burnout. Equally, the converse might be true. Therefore, a cyclical model is put forward in which we propose that elevated levels of burnout from all sources might increase vulnerability to victimization. Increases in emotional exhaustion lead directly to an increase in depersonalization as a coping mechanism, which subsequently manifests as a negative behavioural change toward patients, thus rendering staff more vulnerable to further aggression.

Approval Ratings of Inpatient Coercive Interventions in a National Sample of Mental Health Service Users and Staff in England

OBJECTIVE This study sought to ascertain the degree to which psychiatric inpatients and staff approved of various coercive measures commonly used in acute inpatient care. METHODS A cross-sectional design was adopted. The Attitudes to Containment Measures Questionnaire (ACMQ) was completed by 1,361 service users and 1,226 staff (68% nurses) in acute care mental health services from three regions of England. This provided evaluation of 11 coercive measures (for example, seclusion) on six dimensions of approval (for example, whether the coercive measure is seen as being acceptable or safe to use) in a large national sample. Comparisons between groups were tested with independent-samples t tests, chi square analysis, or Spearman correlations. RESULTS Service users and staff strongly disapproved of net beds and mechanical restraint. The three methods that received the most approval by the service user group were intermittent observation, time out, and PRN (as needed) medication; for the staff group, the three methods that were most approved of were transfer to a psychiatric intensive care unit, PRN medication, and observation. Male staff, older service users, and staff who had been involved in implementing coercion expressed greater approval of coercive measures. CONCLUSIONS There are clear gender differences in how coercive measures that are used in inpatient settings are viewed. Personal involvement in deploying coercive interventions was linked to greater acceptance, suggesting a link between experience and attitudinal changes.

Violence in psychiatric hospitals

Violence was recognized and acknowledged as a problem in psychiatric hospitals much sooner than in other settings and, as a result, more research has been carried out in hospitals. In this chapter three main aspects of violence in psychiatric hospitals will be discussed: (i) the nature of such violence (frequency and severity); (ii) the patients who are more likely to engage in such behaviour; and (iii) the situations where violence is more likely to occur. It will become clear that recent research has focused on the first two areas and insufficient attention has been paid to the assaultive situation. Only when environmental and interpersonal factors are included in our explanations of why violence occurs in psychiatric hospitals will effective interventions to deal with the problem be made.

Prevalence and predictors of early traumatic stress reactions in assaulted psychiatric nurses

Abstract The effects of workplace violence were investigated in a group of 39 psychiatric nurses. Comparisons were made between assaulted nurses and a control group matched for age and occupational grade. The dependent variables were traumatic stress responses, general psychological distress, concurrent stressors and workplace danger. Most assaults were physically minor but two participants (5%) met the criteria for a diagnosis of post-traumatic stress disorder (PTSD). Assaulted staff reported poorer mental health than controls and poorer anger control than at baseline. Psychological distress was higher following assaults resulting in physical injury and staff who were repeatedly assaulted reported either significantly higher or significantly lower distress than those assaulted once. This may indicate early differentiation into violence-distressed and violence-habituated groups.

Violence in a general hospital: comparison of assailant and other assault-related factors on accident and emergency and inpatient wards.

Objective:  This study sought to compare the characteristics of aggressive incidents occurring on inpatient (medical and surgical) wards with those occurring in the accident and emergency department in terms of assailant, employee and other factors.

Relationship between service ecology, special observation and self-harm during acute in-patient care: City-128 study

BACKGROUND Special observation (the allocation of nurses to watch over nominated patients) is one means by which psychiatric services endeavour to keep in-patients safe from harm. The practice is both contentious and of unknown efficacy. AIMS To assess the relationship between special observation and self-harm rates, by ward, while controlling for potential confounding variables. METHOD A multivariate cross-sectional study collecting data on self-harm, special observation, other conflict and containment, physical environment, patient and staff factors for a 6-month period on 136 acute-admission psychiatric wards. RESULTS Constant special observation was not associated with self-harm rates, but intermittent observation was associated with reduced self-harm, as were levels of qualified nursing staff and more intense programmes of patient activities. CONCLUSIONS Certain features of nursing deployment and activity may serve to protect patients. The efficacy of constant special observation remains open to question.

Evaluation of behavioral changes and subjective distress after exposure to coercive inpatient interventions

BackgroundThere is a lack of evidence to underpin decisions on what constitutes the most effective and least restrictive form of coercive intervention when responding to violent behavior. Therefore we compared ratings of effectiveness and subjective distress by 125 inpatients across four types of coercive interventions.MethodsEffectiveness was assessed through ratings of patient behavior immediately after exposure to a coercive measure and 24 h later. Subjective distress was examined using the Coercion Experience Scale at debriefing. Regression analyses were performed to compare these outcome variables across the four types of coercive interventions.ResultsUsing univariate statistics, no significant differences in effectiveness and subjective distress were found between the groups, except that patients who were involuntarily medicated experienced significant less isolation during the measure than patients who underwent combined measures. However, when controlling for the effect of demographic and clinical characteristics, significant differences on subjective distress between the groups emerged: involuntary medication was experienced as the least distressing overall and least humiliating, caused less physical adverse effects and less sense of isolation. Combined coercive interventions, regardless of the type, caused significantly more physical adverse effects and feelings of isolation than individual interventions.ConclusionsIn the absence of information on individual patient preferences, involuntary medication may be more justified than seclusion and mechanical restraint as a coercive intervention. Use of multiple interventions requires significant justification given their association with significant distress.

A systematic review of prevention and intervention strategies for populations at high risk of engaging in violent behaviour: update 2002-8.

BACKGROUND It has been estimated that violence accounts for more than 1.6 million deaths worldwide each year and these fatal assaults represent only a fraction of all assaults that actually occur. The problem has widespread consequences for the individual and for the wider society in physical, psychological, social and economic terms. A wide range of pharmacological, psychosocial and organisational interventions have been developed with the aim of addressing the problem. This review was designed to examine the effectiveness of these interventions when they are developed in mental health and criminal justice populations. OBJECTIVE To update a previous review that examined the evidence base up to 2002 for a wide range of pharmacological, psychosocial and organisational interventions aimed at reducing violence, and to identify the key variables associated with a significant reduction in violence. DATA SOURCES Nineteen bibliographic databases were searched from January 2002 to April 2008, including PsycINFO (CSA) MEDLINE (Ovid), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED), British Nursing Index/Royal College of Nursing, International Bibliography of the Social Sciences (IBSS), Education Resources Information Center (ERIC)/International ERIC, The Cochrane Library (Cochrane reviews, other reviews, clinical trials, methods studies, technology assessments, economic evaluations), Web of Science [Science Citation Index Expanded (SCIE), Social Sciences Citation Index (SSCI), Arts & Humanities Citation Index (A&HCI)]. REVIEW METHODS The assessment was carried out according to accepted procedures for conducting and reporting systematic reviews, including identification of studies, application of inclusion criteria, data extraction and appropriate analysis. Studies were included in meta-analyses (MAs) if they followed a randomised control trial (RCT) design and reported data that could be converted into odds ratios (ORs). For each MA, both a fixed-effects model and a random-effects model were fitted, and both Q statistic and I2 estimates of heterogeneity were performed. RESULTS A total of 198 studies were identified as meeting the inclusion criteria; of these, 51 (26%) were RCTs. Bivariate analyses exploring possible sources of variance in whether a study reported a statistically significant result or not, identified six variables with a significant association. An outcome was less likely to be positive if the primary intervention was something other than a psychological or pharmacological intervention, the study was conducted in an penal institution, the comparator was another active treatment or treatment as usual and if a between-groups design had been used. An outcome was more likely to be positive if it was conducted with people with a mental disorder. The variation attributable to these variables when added to a binary logistic regression was not large (Cox and Snell R(2) = 0.12), but not insignificant given the small number of variables included. The pooled results of all included RCTs suggested a statistically significant advantage for interventions over the various comparators [OR 0.59, 95% confidence interval (CI) 0.53 to 0.65, fixed effects; OR 0.35, 95% CI 0.26 to 0.49 random effects, 40 studies]. However, there was high heterogeneity {I(2) = 86, Q = 279 [degrees of freedom (df) = 39], p < 0.0001}, indicating the need for caution in interpreting the observed effect. Analysis by subgroups showed that most results followed a similar pattern, with statistically significant advantages of treatments over comparators being suggested in fixed- and/or random-effects models but in the context of large heterogeneity. Three exceptions were atypical antipsychotic drugs [OR 0.21, 95% CI 0.16 to 0.27, fixed effects; OR 0.24, 95% CI 0.14 to 0.43, random effects; 10 studies, I(2) = 72.2, Q = 32.4 (df = 9), p < 0.0001], psychological interventions [OR 0.63, 95% CI 0.48 to 0.83, fixed effects; OR 0.53, 95% CI 0.31 to 0.93, random effects; nine studies, I(2) = 62.1, Q = 21.1 (df = 8), p = 0.007] and cognitive behavioural therapy (CBT) as a primary intervention [OR 0.61, 95% CI 0.42 to 0.88, fixed effects; OR 0.61, 95% CI 0.37 to 0.99, random effects; seven studies, I(2) = 21.6, Q = 7.65 (df = 6), p = 0.26]. LIMITATIONS The heterogenity of the included studies inhibits both robust MA and the clear application of findings to establishing improvements in clinical practice. CONCLUSIONS Results from this review show small-to-moderate effects for CBT, for all psychological interventions combined, and larger effects for atypical antipsychotic drugs, with relatively low heterogeneity. There is also evidence that interventions targeted at mental health populations, and particularly male groups in community settings, are well supported, as they are more likely to achieve stronger effects than interventions with the other groups. Future work should focus on improving the quality of evidence available and should address the issue of heterogenity in the literature. FUNDING The National Institute for Health Research Health Technology Assessment programme and the Research for Patient Benefit programme.

Does the position of restraint of disturbed psychiatric patients have any association with staff and patient injuries

The aim of this study was to examine the risk of injury among patients and staff following involvement in a restraint episode in relation to restraint position (standing, supine or prone) and other aspects of the pre-incident behaviour including perceived causation. Mixed effects logistic regression was used to estimate the relative odds of injury to staff or patient in a series of 680 restraint episodes involving 260 patients in an adult mental health service in England between 1999 and 2001. There was no statistically significant association between patient injury and restraint position in this sample, but a prone restraint position was weakly associated with staff injury. Staff injury was most likely when an actual assault had occurred prior to the incident. Patient injury was more likely when the patient had self-harmed, had been abusing substances and had used a weapon prior to the incident, and less likely when the patient was showing signs of frustration with their environment. The use of prone restraint may be weakly associated with an increased risk of injury to staff. However, other aspects of the incident are stronger predictors and should be considered when planning training for front line staff.