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Singal S, Howell D, Hanna L, Tang SX, Van Meter A, Saito E, Kane JM, Michaels TI. Race-Based Disparities in the Frequency and Duration of Restraint Use in a Psychiatric Inpatient Setting. Psychiatr Serv 2024; 75:308-315. [PMID: 37855100 DOI: 10.1176/appi.ps.20230057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
OBJECTIVE Patients' race and age have each been identified as risk factors for experiencing restraint events during psychiatric hospitalization. Restraint duration is also an important variable in determining disparities in treatment. To the authors' knowledge, no studies to date have examined the effect of the interaction of race and age on restraint use and duration in inpatient psychiatric settings. This retrospective chart review of electronic medical records of patients admitted between 2012 and 2019 sought to examine whether race and age interacted in predicting differences in the use and duration of restraints in a psychiatric inpatient setting. METHODS Logistic and hierarchical regression analyses were conducted on data from a sample of 29,739 adolescent (ages 12-17 years) and adult (ages ≥18 years) inpatients to determine whether the interaction of race and age group (adolescent or adult) significantly predicted a restraint event or differences in restraint duration. RESULTS Black (adjusted OR [AOR]=1.85) and multiracial (AOR=1.36) patients were more likely to experience a restraint event than were their White peers. Black race was also significantly (p=0.001) associated with longer restraint duration. No significant interaction was detected between race and age in predicting restraint events or duration. CONCLUSIONS Although the interaction between race and age did not predict restraint events or duration, the findings indicate racial disparities in the frequency and duration of restraint events among Black and multiracial individuals and may inform efforts to reduce these events.
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Affiliation(s)
- Sonali Singal
- Institute of Behavioral Science, Feinstein Institutes for Medical Research, Manhasset, New York (Singal, Tang, Kane); Department of Clinical Psychology, Graduate School of Applied and Professional Psychology, Rutgers, State University of New Jersey, New Brunswick (Singal); Donald and Barbara Zucker School of Medicine, Hofstra/Northwell Health, Hempstead, New York (Howell, Hanna, Kane, Michaels); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York (Hanna, Tang, Van Meter, Saito, Michaels); Department of Child and Adolescent Psychiatry, Grossman School of Medicine, New York University, New York City (Van Meter)
| | - Danielle Howell
- Institute of Behavioral Science, Feinstein Institutes for Medical Research, Manhasset, New York (Singal, Tang, Kane); Department of Clinical Psychology, Graduate School of Applied and Professional Psychology, Rutgers, State University of New Jersey, New Brunswick (Singal); Donald and Barbara Zucker School of Medicine, Hofstra/Northwell Health, Hempstead, New York (Howell, Hanna, Kane, Michaels); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York (Hanna, Tang, Van Meter, Saito, Michaels); Department of Child and Adolescent Psychiatry, Grossman School of Medicine, New York University, New York City (Van Meter)
| | - Lauren Hanna
- Institute of Behavioral Science, Feinstein Institutes for Medical Research, Manhasset, New York (Singal, Tang, Kane); Department of Clinical Psychology, Graduate School of Applied and Professional Psychology, Rutgers, State University of New Jersey, New Brunswick (Singal); Donald and Barbara Zucker School of Medicine, Hofstra/Northwell Health, Hempstead, New York (Howell, Hanna, Kane, Michaels); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York (Hanna, Tang, Van Meter, Saito, Michaels); Department of Child and Adolescent Psychiatry, Grossman School of Medicine, New York University, New York City (Van Meter)
| | - Sunny X Tang
- Institute of Behavioral Science, Feinstein Institutes for Medical Research, Manhasset, New York (Singal, Tang, Kane); Department of Clinical Psychology, Graduate School of Applied and Professional Psychology, Rutgers, State University of New Jersey, New Brunswick (Singal); Donald and Barbara Zucker School of Medicine, Hofstra/Northwell Health, Hempstead, New York (Howell, Hanna, Kane, Michaels); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York (Hanna, Tang, Van Meter, Saito, Michaels); Department of Child and Adolescent Psychiatry, Grossman School of Medicine, New York University, New York City (Van Meter)
| | - Anna Van Meter
- Institute of Behavioral Science, Feinstein Institutes for Medical Research, Manhasset, New York (Singal, Tang, Kane); Department of Clinical Psychology, Graduate School of Applied and Professional Psychology, Rutgers, State University of New Jersey, New Brunswick (Singal); Donald and Barbara Zucker School of Medicine, Hofstra/Northwell Health, Hempstead, New York (Howell, Hanna, Kane, Michaels); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York (Hanna, Tang, Van Meter, Saito, Michaels); Department of Child and Adolescent Psychiatry, Grossman School of Medicine, New York University, New York City (Van Meter)
| | - Ema Saito
- Institute of Behavioral Science, Feinstein Institutes for Medical Research, Manhasset, New York (Singal, Tang, Kane); Department of Clinical Psychology, Graduate School of Applied and Professional Psychology, Rutgers, State University of New Jersey, New Brunswick (Singal); Donald and Barbara Zucker School of Medicine, Hofstra/Northwell Health, Hempstead, New York (Howell, Hanna, Kane, Michaels); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York (Hanna, Tang, Van Meter, Saito, Michaels); Department of Child and Adolescent Psychiatry, Grossman School of Medicine, New York University, New York City (Van Meter)
| | - John M Kane
- Institute of Behavioral Science, Feinstein Institutes for Medical Research, Manhasset, New York (Singal, Tang, Kane); Department of Clinical Psychology, Graduate School of Applied and Professional Psychology, Rutgers, State University of New Jersey, New Brunswick (Singal); Donald and Barbara Zucker School of Medicine, Hofstra/Northwell Health, Hempstead, New York (Howell, Hanna, Kane, Michaels); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York (Hanna, Tang, Van Meter, Saito, Michaels); Department of Child and Adolescent Psychiatry, Grossman School of Medicine, New York University, New York City (Van Meter)
| | - Timothy I Michaels
- Institute of Behavioral Science, Feinstein Institutes for Medical Research, Manhasset, New York (Singal, Tang, Kane); Department of Clinical Psychology, Graduate School of Applied and Professional Psychology, Rutgers, State University of New Jersey, New Brunswick (Singal); Donald and Barbara Zucker School of Medicine, Hofstra/Northwell Health, Hempstead, New York (Howell, Hanna, Kane, Michaels); Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York (Hanna, Tang, Van Meter, Saito, Michaels); Department of Child and Adolescent Psychiatry, Grossman School of Medicine, New York University, New York City (Van Meter)
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Moell A, Rozental A, Buchmayer S, Kaltiala R, Långström N. Effects of stricter legislation on coercive measures in child and adolescent psychiatric care: a qualitative interview study with staff. BMC Psychiatry 2024; 24:102. [PMID: 38317134 PMCID: PMC10845720 DOI: 10.1186/s12888-024-05553-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 01/23/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Legislators often want to positively affect psychiatric inpatient care and reduce coercion by a stricter judicial regulation. However, staff experiences and comprehension of such legal changes are largely unknown, yet essential in obtaining the intended outcomes. We examined staff understanding and implementation of a July 1, 2020 legal change in Sweden regarding the use of coercive measures (e.g., restraint, seclusion, and forced medication) in child and adolescent psychiatric inpatient care. METHODS During 2021, semi-structured interviews were conducted with nine child and adolescent psychiatric inpatient staff (nurses, senior consultants, and head of units). Interviews were transcribed verbatim and analysed using reflexive thematic analysis. We used an implementation outcomes framework to relate data to a wider implementation science context. RESULTS The legislative change was viewed as both positive and negative by participating staff. They reported mixed levels of preparedness for the legislative change, with substantial challenges during the immediate introduction, including insufficient preparations and lack of clear guidelines. A knowledge hierarchy was evident, affecting various professional roles differently. While the law was positively viewed for its child-centred approach, we found notable distrust in legislators' understanding of the clinical reality, leading to practical difficulties in implementation. Care practices after the legal change varied, with some participants reporting little change in the use of coercive measures, while others noted a shift towards more seclusion and sedative medication usage. The work environment for consultants was described as more challenging due to increased bureaucratic procedures and a heightened pressure for accuracy. CONCLUSIONS The study highlights the complexities and challenges in implementing legislative changes in psychiatric care, where stricter legislation does not necessarily entail reduced use of coercion.
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Affiliation(s)
- Astrid Moell
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Alexander Rozental
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Susanne Buchmayer
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Riittakerttu Kaltiala
- Faculty of Medicine and Health Technology, and Tampere University Hospital, Department of Adolescent Psychiatry, Tampere University, Tampere, Finland
| | - Niklas Långström
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Matte-Landry A, Collin-Vézina D. Patterns of change in restrictive measures in residential care: Trauma-informed staff training benefits children and youth who need it the Most. CHILD ABUSE & NEGLECT 2024; 147:106576. [PMID: 38043458 DOI: 10.1016/j.chiabu.2023.106576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 09/08/2023] [Accepted: 11/20/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Implementation of trauma-informed staff training is promising to reduce restrictive measures (restraints, seclusions, and time-outs) used to address problem behaviors in youth in residential care. Previous mixed results may be explained in part by the heterogeneity in the use of restrictive measures among youth. OBJECTIVE The objective was twofold: (1) to examine whether heterogeneity in the initial number of restrictive measures experienced by youth, before implementing trauma-informed staff training, moderates the effect of the training and (2) to explore whether children and youth's characteristics are associated with the number of restrictive measures. PARTICIPANTS AND SETTING A trauma-informed staff training was implemented in 44 residential care units in Quebec, Canada. METHODS This study used administrative data. The sample (n = 297 youth) was divided into three subgroups based on the number of restrictive measures experienced in the six-month period prior to the training: 1) absence or low (52 % of the sample); 2) moderate (23 %); 3) high (25 %). RESULTS The use of restrictive measures was compared between the subgroups. Main and interaction effects were all significant. None of the slopes for groups 1 and 2 were significant. In contrast, significant decreases from T1 were observed at T2 (-0.18 (0.02), p < .000) and T3 (-0.22 (0.02), p < .000) in group 3. Several children and youth's characteristics distinguished groups. CONCLUSIONS Implementation was more beneficial to youth who experienced a high number of restrictive measures. Training opportunities can lead to positive changes in measures used to address problem behaviors in youth.
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Affiliation(s)
- Alexandra Matte-Landry
- School of Social Work and Criminology, Université Laval, Quebec City, Canada; Centre de recherche universitaire sur les jeunes et les familles, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Quebec City, Canada; Centre de recherche Jeunes, familles et réponses sociales, Quebec City, Canada.
| | - Delphine Collin-Vézina
- Centre de recherche universitaire sur les jeunes et les familles, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Quebec City, Canada; Centre for Research on Children and Families, School of Social Work, McGill University, Montreal, Canada
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4
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Greenwald A, Kelly A, Thomas L. Trauma-informed care in the emergency department: concepts and recommendations for integrating practices into emergency medicine. MEDICAL EDUCATION ONLINE 2023; 28:2178366. [PMID: 36799730 PMCID: PMC9946309 DOI: 10.1080/10872981.2023.2178366] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 01/08/2023] [Accepted: 02/06/2023] [Indexed: 06/18/2023]
Abstract
The experience of psychological trauma is common and has become even more prevalent during the COVID-19 pandemic for both health care workers and the general population [1-3]. Traumatic experiences can have varied and lasting physical and mental health effects on patients, beyond what we are privy to in the acute environment of the emergency department. The effects of these prior traumatic experiences can be exacerbated by interaction with the healthcare system, and yet emergency medicine physicians have no standardized methods for working with patients in a trauma-informed way. The systematic implementation of trauma-informed care (TIC) practice requires the cooperation of multiple domains within the health care system, including focus on the physical environment, direct care, and administrative practices. Here we provide recommendations specific to emergency medicine for the development and implementation of TIC in the regular patient-clinician interaction, situated within the context of the TIC framework as outlined by the Substance Abuse and Mental Health Services Administration (SAMHSA) [4].
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Affiliation(s)
- Audria Greenwald
- Department of Medical Sciences, Frank H. Netter School of Medicine at Quinnipiac University, North Haven, CT, USA
| | - Amber Kelly
- Department of Medical Sciences, Frank H. Netter School of Medicine at Quinnipiac University, North Haven, CT, USA
| | - Listy Thomas
- Department of Social Work, Quinnipiac University School for Health Sciences, North Haven, CT, USA
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5
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Soto J, Mitchell TO, Masters KJ, Millard H. The Role of Psychiatrists in Seclusion and Restraint Episodes: a Curriculum for Psychiatric Trainees. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2023; 47:676-679. [PMID: 36952217 DOI: 10.1007/s40596-023-01767-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 03/03/2023] [Indexed: 06/18/2023]
Affiliation(s)
- Jessica Soto
- Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | | | - Kim J Masters
- College of Health Professions Medical University of South Carolina, Charleston, SC, USA
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Bergström T, Kurtti M, Miettunen J, Yliruka L, Valtanen K. Out-of-home interventions for adolescents who were treated according to the Open Dialogue model for mental health care. CHILD ABUSE & NEGLECT 2023; 145:106408. [PMID: 37634324 DOI: 10.1016/j.chiabu.2023.106408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 07/27/2023] [Accepted: 08/14/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND The Open Dialogue approach (OD) emphasizes community-based psychiatric treatment for adolescents, but its success in achieving this is poorly documented. OBJECTIVE To analyse out-of-home intervention usage in a national sample of adolescent psychiatric patients and determine if OD is linked to increased time until out-of-home intervention. PARTICIPANTS AND SETTING The register-based cohort study included all adolescents aged 13-20 who received psychiatric treatment in Finland between 2003 and 2008. The research group (n = 780) included adolescents whose treatment was initiated in the Western Lapland catchment area, where OD covered the entire psychiatric service. The comparison group (n = 44,088) included the rest of Finland. National register data encompassed the period from treatment onset until the end of the 10-year follow-up or death. The primary outcomes of interest were the times to the first and second out-of-home intervention, including foster care, supportive housing, and hospitalization. The secondary outcomes included the clinical/demographic characteristics of adolescents treated out-of-home. METHODS The hypothesis was tested via an inverse probability of treatment-weighted Cox hazard model, plus within- and between-group comparisons to analyse the secondary outcome. RESULTS OD was associated with increased time to the first (adjusted hazard ratio [aHR]: 0.61, 95%CI: 0.52-0.72) and second (aHR: 0.75, 95%CI: 0.58-0.96) out-of-home interventions. In both service types, there was a subgroup of adolescents with repeated out-of-home interventions, who also demonstrated poorer long-term outcomes. CONCLUSION OD-based psychiatric services for adolescents are associated with fewer out-of-home interventions. The clinical significance of the findings warrants further research.
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Affiliation(s)
- Tomi Bergström
- Department of Psychology, University of Jyväskylä, Jyväskylä, Finland; Department of Psychiatry, Wellbeing service county of Lapland, Kemi, Finland.
| | - Mia Kurtti
- Department of Psychiatry, Wellbeing service county of Lapland, Kemi, Finland
| | - Jouko Miettunen
- Research Unit of Population Health, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Laura Yliruka
- The Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Kari Valtanen
- Department of Psychiatry, Wellbeing service county of Lapland, Kemi, Finland
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7
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Kelly P, Saab MM, Hurley EJ, Heffernan S, Goodwin J, Mulud ZA, O Malley M, O Mahony J, Curtin M, Groen G, Ivanova S, Jörns-Presentati A, Korhonen J, Kostadinov K, Lahti M, Lalova V, Petrova G, O Donovan A. Trauma Informed Interventions to Reduce Seclusion, Restraint and Restrictive Practices Amongst Staff Caring for Children and Adolescents with Challenging Behaviours: A Systematic Review. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2023; 16:629-647. [PMID: 37593061 PMCID: PMC10427579 DOI: 10.1007/s40653-023-00524-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 08/19/2023]
Abstract
Engaging with children and adolescents in mental health settings who are exhibiting behaviours that challenge can often result in the use of seclusion, restraint and coercive practices. It is recognised that more therapeutic ways to engage this population are needed, adopting trauma informed interventions may provide a solution. The aim of this systematic review is to synthesize the evidence in relation to the effect of trauma-informed interventions on coercive practices in child and adolescent residential settings. The review is guided by elements of the Cochrane Handbook for Systematic Reviews of Interventions and reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist. Results were synthesized and reported narratively. Nine studies met the eligibility criteria for this review. There was a lack of homogeneity amongst the studies. The trauma-informed interventions used were typically multi-faceted, underpinned by a variety of approaches and sought to bring about changes to clinical practice. Most studies (n = 8) reported significant reductions in the use of restrictive practices following the implementation of a trauma informed approach. The use of a trauma-informed approach, underpinned by an organisational change or implementation strategy, have the potential to reduce coercive practices with children and adolescents. However, the included interventions were insufficiently described to draw strong conclusions.
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Affiliation(s)
- Peter Kelly
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Mohamad M. Saab
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Emma J. Hurley
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Sinéad Heffernan
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - John Goodwin
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Zamzaliza A. Mulud
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
- Centre for Nursing Studies, Universiti Teknologi MARA Selangor, Puncak Alam, Selangor, Malaysia
| | - Maria O Malley
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - James O Mahony
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Margaret Curtin
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Gunter Groen
- Sciences Hamburg Department of Social Work, University of Applied, Hamburg, Germany
| | - Svetla Ivanova
- Department of Nursing Care, Faculty of Public Health, Medical University of Plovdiv, Plovdiv, Bulgaria
| | | | - Joonas Korhonen
- Faculty of Health and Well-Being, Turku University of Applied Science, Turku, Finland
| | - Kostadin Kostadinov
- Department of Social Medicine and Public Health, Faculty of Public Health, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Mari Lahti
- Faculty of Health and Well-Being, Turku University of Applied Science, Turku, Finland
| | - Valentina Lalova
- Department of Nursing Care, Faculty of Public Health, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Gergana Petrova
- Department of Nursing Care, Faculty of Public Health, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Aine O Donovan
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
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8
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Vidal C, Reynolds EK. Understanding staff perceptions on adolescent seclusions. Evid Based Nurs 2023:ebnurs-2023-103702. [PMID: 37479468 DOI: 10.1136/ebnurs-2023-103702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2023] [Indexed: 07/23/2023]
Affiliation(s)
- Carol Vidal
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth K Reynolds
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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9
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Schepker R, Keller F, Fegert JM. [Trends in Adolescents' Satisfaction with Their Inpatient Psychiatric Treatment: A Panel Analysis over 7 Years]. ZEITSCHRIFT FUR KINDER- UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2023; 51:283-293. [PMID: 36524383 DOI: 10.1024/1422-4917/a000911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Trends in Adolescents' Satisfaction with Their Inpatient Psychiatric Treatment: A Panel Analysis over 7 Years Abstract. Because the German legislature is increasingly enabling adolescents' participation in their psychiatric treatment, we traced changes in satisfaction of 6,893 patients at the end of their stay in 10 hospitals using BEST-J. The treatments resulted in a fair overall satisfaction without any improvement over the 7 years studied. In seven hospitals, we calculated deviation from the overall satisfaction based on annual surveys. Satisfaction with the psychotherapeutic relationship was good from the beginning, whereas the relationship with caregivers improved during the sample period. When new legal standards were introduced, we measured an improvement in some items concerning patient participation (coercive measures information, goals of treatment discussed). Patients were less satisfied with the information about their illness than with medication information. Initially poor satisfaction with leave regulations significantly improved over time. Respect for privacy also improved. Satisfaction with the environment and service organization scored substantially worse than the other items. Peer relations within the ward were rated close to overall satisfaction. The results point to benefits from training in psychotherapy and a growing awareness of closeness-distance issues and patients' rights. Nevertheless, psychoeducation and leave regulations require improvement. Furthermore, patients stated unmet needs for refurbishing and renovating buildings.
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Affiliation(s)
- Renate Schepker
- Klinik für Kinder- und Jugendpsychiatrie/ Psychotherapie, Universitätsklinikum Ulm, Deutschland
| | - Ferdinand Keller
- Klinik für Kinder- und Jugendpsychiatrie/ Psychotherapie, Universitätsklinikum Ulm, Deutschland
| | - Jörg Michael Fegert
- Klinik für Kinder- und Jugendpsychiatrie/ Psychotherapie, Universitätsklinikum Ulm, Deutschland
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10
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Daniels TE, Victor C, Smith EM, Belgrave C, Robinson E, Wolff JC, Hunt J, Brannan EH. Associations of Restraint and Seclusion With Race and Ethnicity on an Adolescent Inpatient Psychiatry Service. J Am Acad Child Adolesc Psychiatry 2023; 62:503-506. [PMID: 36736689 PMCID: PMC10543036 DOI: 10.1016/j.jaac.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/30/2022] [Accepted: 01/24/2023] [Indexed: 02/01/2023]
Abstract
There is limited work examining the association of race and ethnicity with restraint and seclusion (R/S) in pediatric inpatient psychiatric units. The present study assessed risk of R/S by race and ethnicity based on a retrospective review of electronic medical records (EMRs) from an adolescent inpatient psychiatric service. Demographic, diagnostic, and R/S data were analyzed for all 1,865 admissions of 1,327 patients from an adolescent unit at a child and adolescent psychiatric hospital from June 2018 to June 2021. R/S occurred in 459 of the admissions. For the purpose of patient privacy and statistical analysis, race was grouped into the following: Black or African American, other (American Indian or Alaskan Native, Asian, multiracial, other), and White. Patients identified as unknown were not included in the analysis. A binary logistic regression with a repeated subject effect regressed R/S onto race and adjusted for age, gender, and length of stay (LOS). There was an overall significant association of R/S and race (χ22 = 16.81, p < .001), but not ethnicity. In a regression model adjusted for age, gender, and LOS, patients identified as Black or African American were at significantly higher risk of R/S compared with patients identified as White (odds ratio = 1.66, p = .036). There was no significant difference in risk of R/S between patients identified as White vs other. Younger age and longer LOS were also significantly associated with R/S. These findings highlight a critical health care disparity related to race on an inpatient adolescent psychiatry service. There is likely a combination of individual and systemic factors leading to discriminatory practices in the use of R/S. Future work will assess potential associations with diagnosis and child welfare involvement and will examine additional characteristics of R/S. Focus groups held with hospital and community stakeholders will guide next steps to address these findings.
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Affiliation(s)
- Teresa E Daniels
- Warren Alpert Medical School, Brown University, Providence, Rhode Island; Initiative on Stress, Trauma, and Resilience (STAR), Warren Alpert Medical School, Brown University, Providence, Rhode Island.
| | - Colleen Victor
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Eric M Smith
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Christa Belgrave
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Erica Robinson
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Jennifer C Wolff
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Jeffrey Hunt
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
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11
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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. NURSING REPORTS 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] [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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Thompson AD, Berkman ER, Simmons SW, Porter KM, Kroon L, Goldman R, Ramasamy RS. Ethical Considerations in Balancing Use of Seclusion and Restraint With Risk of COVID-19 Exposure: Recommendations for Youth Inpatient Psychiatry Units. J Am Acad Child Adolesc Psychiatry 2022; 61:1319-1321. [PMID: 35513190 PMCID: PMC9057649 DOI: 10.1016/j.jaac.2022.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/05/2022] [Accepted: 04/25/2022] [Indexed: 11/03/2022]
Abstract
The onset of the COVID-19 pandemic has presented unique challenges for inpatient psychiatry units (IPUs). IPUs, especially those caring for children and adolescents, rely heavily on milieu group programming to provide care and supervision for patients, and have had to adapt unit policies and procedures to maintain a therapeutic milieu while minimizing COVID-19 transmission.1 Simultaneously providing care while preventing transmission of COVID-19 within IPUs is a formidable task, and many IPUs face the additional challenge of treating youth who have been exposed to, or are actively infected with, COVID-19. In addition, given the need to prevent transmission of COVID-19, recommendations include "mandatory quarantine and isolation when patients refuse to adhere to guidelines,"2 potentially leading to the use of restraint when patients attempt to leave isolation; thus a conflict between the potential risks of enforcing infection prevention policies in order to reduce virus transmission and best practices of eliminating seclusion and restraint (S/R) creates an ethical dilemma for IPUs.
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Affiliation(s)
- Alysha D. Thompson
- Seattle Children’s Hospital, Washington,University of Washington, Seattle,Correspondence to Alysha D. Thompson, PhD, Seattle Children’s Hospital, University of Washington, 4800 Sand Point Way NE, Seattle, WA 98105
| | - Emily R. Berkman
- Seattle Children’s Hospital, Washington,University of Washington, Seattle
| | - Shannon W. Simmons
- Seattle Children’s Hospital, Washington,University of Washington, Seattle
| | | | | | | | - Ravi S. Ramasamy
- Seattle Children’s Hospital, Washington,University of Washington, Seattle
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Clinical Characteristics of Youth with Autism or Developmental Disability during Inpatient Psychiatric Admission. J Clin Med 2022; 11:jcm11216328. [PMID: 36362556 PMCID: PMC9658441 DOI: 10.3390/jcm11216328] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/16/2022] [Accepted: 10/18/2022] [Indexed: 11/27/2022] Open
Abstract
Children with autism spectrum disorder and developmental disabilities (ASD/DD) often experience severe co-occurring psychological and behavioral challenges, which can warrant inpatient psychiatric care. However, very little is known about the characteristics and clinical care of children with ASD/DD within the context of inpatient psychiatric settings. In this paper, we describe factors unique to inpatients with ASD or DD, by drawing on electronic health records from over 2300 children and adolescents ages 4–17 years admitted to a pediatric psychiatric inpatient unit over a 3-year period. Patients with ASD/DD accounted for approximately 16% of inpatients and 21% of admissions, were younger, more likely to be readmitted, more likely to be male, and more likely to have Medicaid insurance, as compared to patients without ASD/DD. Clinically, those with ASD/DD more frequently had externalizing concerns documented in their records, in contrast to more frequent internalizing concerns among other patients. Within the ASD/DD group, we identified effects of patient age, sex, and race/ethnicity on multiple dimensions of clinical care, including length of stay, use of physical restraint, and patterns of medication use. Results suggest the need for psychiatric screening tools that are appropriate for ASD/DD populations, and intentional integration of anti-racist practices into inpatient care, particularly with regard to use of physical restraint among youth.
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14
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Boulton KA, Raghupathy V, Guastella AJ, Bowden MR. Reducing seclusion use in an Australian child and adolescent psychiatric inpatient unit. J Affect Disord 2022; 305:1-7. [PMID: 35227762 DOI: 10.1016/j.jad.2022.02.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/19/2022] [Accepted: 02/22/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND In inpatient psychiatric units, seclusion (isolation in a locked room) is recommended only as a last resort for serious aggression or agitation. In response to an increase in seclusion during 2015, an 8-bed child and adolescent inpatient unit implemented a suite of multidisciplinary interventions. This study examines changes in seclusion rates following intervention implementation and assesses whether specific patient factors were associated with seclusion rates before and after interventions. METHOD Multi-modal interventions, comprised of patient treatment plans, intake and handover meetings, staff supervision and debriefing sessions, were implemented from January 2016. We compared quarterly seclusion rates (episodes per 1000 patient days) across a thirteen-year period, from July 2008 to June 2021. Change in seclusion rates following intervention was evaluated using a segmented regression analysis. We examined whether patient factors were associated with seclusion rates, and whether the duration of seclusion episodes differed before and after interventions. RESULTS There was a 100% reduction in seclusion rates in the 6 months following intervention implementation, from 28.4 episodes per 1000 patient days in July-September 2015, to 4.7 episodes in January-March 2016, reaching 0.0 episodes by April-June 2016. This reduction was maintained until April-June 2021. Most patients with seclusion events before and after intervention implementation had a neurodevelopmental disorder diagnosis and a minority of patients accounted for most seclusion events. There was a 65% reduction in the average duration of seclusion episodes following interventions, however this was not statistically significant. LIMITATIONS Due to a crisis in staff morale, interventions were implemented simultaneously, preventing an understanding of whether a single intervention accounted for change. While not addressed in the current study, assessing perceptions of staff, children and parents following intervention implementation may have elucidated barriers and facilitators to change. CONCLUSIONS Multidisciplinary, patient-centered interventions may be effective for long-term reduction of seclusion rates in inpatient psychiatric units. These findings highlight patient factors associated with seclusion reduction which should be considered when implementing interventions.
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Affiliation(s)
- Kelsie A Boulton
- Autism Clinic for Translational Research, Brain and Mind Centre, Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Child Neurodevelopment and Mental Health Team, Brain and Mind Centre, Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Veena Raghupathy
- Psychological Medicine, Children's Hospital at Westmead, Sydney Children's Hospital Network, Sydney, Australia
| | - Adam J Guastella
- Autism Clinic for Translational Research, Brain and Mind Centre, Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Child Neurodevelopment and Mental Health Team, Brain and Mind Centre, Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
| | - Michael R Bowden
- Psychological Medicine, Children's Hospital at Westmead, Sydney Children's Hospital Network, Sydney, Australia; Mental Health - Children and Young People, Mental Health Branch, NSW Health, Sydney, Australia; Faculty of Medicine and Health, Sydney Medical School, University of Sydney, Sydney, Australia
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15
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Trends in admissions to a child and adolescent neuropsychiatric inpatient unit in the 2007-2017 decade: how contemporary neuropsychiatry is changing in Northwestern Italy. Eur Child Adolesc Psychiatry 2022; 31:1527-1537. [PMID: 33914133 PMCID: PMC9532329 DOI: 10.1007/s00787-021-01794-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 04/19/2021] [Indexed: 11/14/2022]
Abstract
PURPOSE Rising levels of psychopathology in the adolescent population have been evidenced in the last few years throughout the Western world. We aim to examine how contemporary neuropsychiatry is changing in Northwestern Italy and how this impacts inpatient services. METHODS The present research considered the 1177 admissions to a public neuropsychiatric inpatient service in the 2007-2017 decade. The annual percentual change (APC) was analysed for the total admissions, the number of the neurological vs psychiatric admissions, the length of inpatient stay, and the mean age at admission, also accounting for sex differences. The annual trend was also calculated for each diagnosis. RESULTS The overall number of inpatient admissions decreased significantly (APC = - 5.91), in particular for children under 12 years of age (APC = - 7.23). The rate of neurologic diagnoses significantly decreased (APC = - 26.44), while the length of the inpatient stay (APC = 6.98) and the mean age at admission (APC = 6.69) increased. Among the psychiatric diagnoses, depression significantly rose (APC = 41.89), in particular among female adolescents (APC = 40.30). CONCLUSIONS These data document a substantial change in the utilization of inpatient neuropsychiatric services for children and adolescents, with a major increase in psychiatric hospitalizations and a parallel decrease in neurological ones. These trends call for greater attention to early preventive intervention in mental healthcare system.
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