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Ngune I, Myers H, Cole A, Palamara P, Redknap R, Roche M, Twigg D. Developing nurse-sensitive outcomes in acute inpatient mental health settings-A systematic review. J Clin Nurs 2023; 32:6254-6267. [PMID: 36915223 DOI: 10.1111/jocn.16679] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 12/14/2022] [Accepted: 01/30/2023] [Indexed: 03/15/2023]
Abstract
BACKGROUND While nurse-sensitive outcomes (NSOs) are well established in numerous health settings, to date there is no indicator suite of NSOs for inpatient mental health settings. AIM To assess the relationship between nursing variables and patient outcomes in acute inpatient mental health settings to determine which outcomes can be used as indicators of the quality of nursing care. METHODS Databases accessed were CINAHL, MEDLINE, PsycINFO and EMBASE, last searched in May 2022. The review followed the 2020 PRISMA checklist for systematic reviews. Papers published between 1995 and 2022, conducted in acute mental health care units were included. The quality of the studies was assessed using the Effective Public Health Practice Project Quality Assessment Tool. A meta-analysis was not possible because of the large number of variables and measurement inconsistencies. RESULTS A total of 57 studies were reviewed. Studies were categorised according to whether they found a significant or non-significant relationship between nurse variables and patient outcomes. Seven outcomes-aggression, seclusion, restraint, absconding, pro-re-nata medications, special observations and self-harm-were identified. For each outcome, there were significant findings for several nurse variables indicating that all included outcomes could be used as NSOs. However, evidence for aggression, seclusion and restraint use as suitable NSOs was more robust than the evidence for self-harm, absconding, pro-re-nata medications and special observations. CONCLUSION All the seven outcomes can all be used to develop an NSO indicator suite in mental health inpatient settings. More work is needed to establish high-quality studies to clearly demonstrate the relationship between these outcome measures and changes in nurse variables such as nurse staffing, skill mix, work environment, nurse education and nurse experience. PATIENT AND PUBLIC CONTRIBUTION Patient or public contribution was not possible because of the type of the variables being explored.
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Affiliation(s)
- Irene Ngune
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Helen Myers
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Amanda Cole
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Peter Palamara
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Robina Redknap
- Western Australia Department of Health, Perth, Western Australia, Australia
| | - Michael Roche
- University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Diane Twigg
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
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Kennedy HG, Mullaney R, McKenna P, Thompson J, Timmons D, Gill P, O’Sullivan OP, Braham P, Duffy D, Kearns A, Linehan S, Mohan D, Monks S, McLoughlin L, O’Connell P, O’Neill C, Wright B, O’Reilly K, Davoren M. A tool to evaluate proportionality and necessity in the use of restrictive practices in forensic mental health settings: the DRILL tool (Dundrum restriction, intrusion and liberty ladders). BMC Psychiatry 2020; 20:515. [PMID: 33097036 PMCID: PMC7583300 DOI: 10.1186/s12888-020-02912-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 10/11/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Prevention of violence due to severe mental disorders in psychiatric hospitals may require intrusive, restrictive and coercive therapeutic practices. Research concerning appropriate use of such interventions is limited by lack of a system for description and measurement. We set out to devise and validate a tool for clinicians and secure hospitals to assess necessity and proportionality between imminent violence and restrictive practices including de-escalation, seclusion, restraint, forced medication and others. METHODS In this retrospective observational cohort study, 28 patients on a 12 bed male admissions unit in a secure psychiatric hospital were assessed daily for six months. Data on adverse incidents were collected from case notes, incident registers and legal registers. Using the functional assessment sequence of antecedents, behaviours and consequences (A, B, C) we devised and applied a multivariate framework of structured professional assessment tools, common adverse incidents and preventive clinical interventions to develop a tool to analyse clinical practice. We validated by testing assumptions regarding the use of restrictive and intrusive practices in the prevention of violence in hospital. We aimed to provide a system for measuring contextual and individual factors contributing to adverse events and to assess whether the measured seriousness of threating and violent behaviours is proportionate to the degree of restrictive interventions used. General Estimating Equations tested preliminary models of contexts, decisions and pathways to interventions. RESULTS A system for measuring adverse behaviours and restrictive, intrusive interventions for prevention had good internal consistency. Interventions were proportionate to seriousness of harmful behaviours. A 'Pareto' group of patients (5/28) were responsible for the majority (80%) of adverse events, outcomes and interventions. The seriousness of the precipitating events correlated with the degree of restrictions utilised to safely manage or treat such behaviours. CONCLUSION Observational scales can be used for restrictive, intrusive or coercive practices in psychiatry even though these involve interrelated complex sequences of interactions. The DRILL tool has been validated to assess the necessity and demonstrate proportionality of restrictive practices. This tool will be of benefit to services when reviewing practices internally, for mandatory external reviewing bodies and for future clinical research paradigms.
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Affiliation(s)
- Harry G. Kennedy
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland ,grid.8217.c0000 0004 1936 9705DUNDRUM Centre for Forensic Excellence, Department of Psychiatry, Trinity College Dublin, Dublin 2, Ireland
| | - Ronan Mullaney
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - Paul McKenna
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - John Thompson
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - David Timmons
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - Pauline Gill
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - Owen P. O’Sullivan
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland ,grid.451052.70000 0004 0581 2008Camlet Lodge Medium Secure Unit, North London Forensic Service, Chase Farm Hospital, Barnet Enfield and Haringey NHS MHT, London, UK
| | - Paul Braham
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - Dearbhla Duffy
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - Anthony Kearns
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland ,grid.8217.c0000 0004 1936 9705DUNDRUM Centre for Forensic Excellence, Department of Psychiatry, Trinity College Dublin, Dublin 2, Ireland
| | - Sally Linehan
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - Damian Mohan
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland ,grid.8217.c0000 0004 1936 9705DUNDRUM Centre for Forensic Excellence, Department of Psychiatry, Trinity College Dublin, Dublin 2, Ireland
| | - Stephen Monks
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland ,grid.8217.c0000 0004 1936 9705DUNDRUM Centre for Forensic Excellence, Department of Psychiatry, Trinity College Dublin, Dublin 2, Ireland
| | - Lisa McLoughlin
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - Paul O’Connell
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland ,grid.8217.c0000 0004 1936 9705DUNDRUM Centre for Forensic Excellence, Department of Psychiatry, Trinity College Dublin, Dublin 2, Ireland
| | - Conor O’Neill
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland ,grid.8217.c0000 0004 1936 9705DUNDRUM Centre for Forensic Excellence, Department of Psychiatry, Trinity College Dublin, Dublin 2, Ireland
| | - Brenda Wright
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland
| | - Ken O’Reilly
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland ,grid.8217.c0000 0004 1936 9705DUNDRUM Centre for Forensic Excellence, Department of Psychiatry, Trinity College Dublin, Dublin 2, Ireland
| | - Mary Davoren
- grid.459431.e0000 0004 0616 8533National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland ,grid.8217.c0000 0004 1936 9705DUNDRUM Centre for Forensic Excellence, Department of Psychiatry, Trinity College Dublin, Dublin 2, Ireland ,Broadmoor High Security Hospital, Berkshire, UK
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Reen GK, Bailey J, Maughan DL, Vincent C. Systematic review of interventions to improve constant observation on adult inpatient psychiatric wards. Int J Ment Health Nurs 2020; 29:372-386. [PMID: 32048785 DOI: 10.1111/inm.12696] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2020] [Indexed: 11/29/2022]
Abstract
Constant observation is frequently conducted on inpatient psychiatric units to manage patients at risk of harming themselves or others. Despite its widespread use, there is little evidence of the efficacy of the practice or of its impact on patients and nursing staff. Unnecessary use of this practice can be restrictive and distressing for all involved and can cause considerable strain on healthcare resources. We sought to review interventions aiming to improve the quality and safety of constant observation or to reduce unnecessary use of this restrictive practice on adult inpatient psychiatric wards. A systematic search conducted in December 2018 using PubMed, PsycINFO, CINAHL, EMBASE and Google Scholar identified 24 studies with interventions related to constant observation. Only 16 studies evaluated a total of 13 interventions. The most common intervention components were changes to team, education and training for staff, changes to record keeping and assessment, and involving patients in care. A range of outcome measures were used to evaluate interventions. Over half of the interventions showed some positive impact on constant observation. One study recorded patient feedback. All interventions were targeted towards mental health nurses. Overall, there is no consensus on how best to improve the safety and quality of constant observations or reduce its unnecessary use. Studies vary widely in design, intervention and outcome measures. Existing research does however suggest that teamwork interventions can improve the patient experience of constant observation and safely reduce their degree and frequency. Priorities for future research on constant observations are highlighted.
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Affiliation(s)
- Gurpreet K Reen
- University of Oxford & Oxford Health NHS Foundation Trust, Oxford, UK
| | - Jill Bailey
- Oxford Health NHS Foundation Trust, Oxford, UK
| | | | - Charles Vincent
- University of Oxford & Oxford Health NHS Foundation Trust, Oxford, UK
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Vahidi M, Ebrahimi H, Areshtanab HN, Jafarabadi MA, West S, Foong A, Cleary M. Providing a Safe Environment in a Psychiatric Ward: Nurses and Vigilance in Iran. Issues Ment Health Nurs 2019; 40:65-72. [PMID: 30204026 DOI: 10.1080/01612840.2018.1463326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The aim of this study was to explore nurses' use of vigilance in the provision of inpatient psychiatric care. In this qualitative exploratory descriptive design study, 16 nurses working in inpatient psychiatric units were recruited through purposive sampling. Data were collected by semi-structured interviews and fieldwork observations and analysed using conventional content analysis. According to participants, nurses' vigilance is related to synthesising knowledge, experience, communication, and presence. This conclusion was derived from four main themes: understanding the context of the psychiatric ward; continuous monitoring; cognitive assessments; and involving others. The study highlights the significance of education for all mental health staff and provision of appropriate information to all patients and their companions about psychiatric disorders and the side effects of prescribed medications. Of importance is the skill of active listening to the concerns of patients and the demonstration of commitment by nurses to follow-up on reports from stakeholders. Imparting the skills and experiences of senior nurses to novice nurses and their presence alongside other nurses on work-shifts can be effective in promoting vigilance.
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Affiliation(s)
- Maryam Vahidi
- a Department of Psychiatric Nursing, Faculty of Nursing and Midwifery , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Hossein Ebrahimi
- a Department of Psychiatric Nursing, Faculty of Nursing and Midwifery , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Hossein Namdar Areshtanab
- a Department of Psychiatric Nursing, Faculty of Nursing and Midwifery , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Mohammad Asghari Jafarabadi
- b Department of Statistics and Epidemiology, Faculty of Health Sciences , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Sancia West
- c School of Health Sciences , University of Tasmania , Sydney , Australia
| | - Andrew Foong
- c School of Health Sciences , University of Tasmania , Sydney , Australia
| | - Michelle Cleary
- c School of Health Sciences , University of Tasmania , Sydney , Australia
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5
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Lienhardt A, Rabenschlag F, Panfil EM. [The practice of special observation in adults in the German-speaking part of Switzerland - a descriptive cross-sectional study]. Pflege 2018; 31:255-265. [PMID: 29882731 DOI: 10.1024/1012-5302/a000621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The practice of special observation in adults in the German-speaking part of Switzerland - a descriptive cross-sectional study Abstract. INTRODUCTION Psychiatric Special Observation (PSO) is an intervention often used by nurses to prevent service users of harming themselves or to protect others. The intervention ranges between control and therapy and is resource intensive. Despite the widespread use of PSO, there is still no data on the practice of the intervention in Switzerland. AIM What is the current practice of PSO in adults in psychiatric hospitals in the German-speaking part of Switzerland? METHOD Descriptive cross-sectional study. Nurses from inpatient psychiatric services in the German-speaking part of Switzerland completed a questionnaire based on a concept analysis of PSO. RESULTS 538 questionnaires were analysed. PSO was more often conducted intermittent than as constant observation. In more than one out of four cases, suicidality reasoned as a cause for prescription. Nurses generally used standardized instruments to assess the risk of harming oneself or others. The duration of PSO lasted eight hours or more in three out of four cases. In every fifth case, there was no validation of the need of the intervention taking place during one shift. Nurses have a neutral attitude towards the intervention and are experiencing no or weak negative feelings during performance of PSO. CONCLUSIONS The results suggest that there is an inconsistent performance of PSO in Switzerland as well as in other countries. The validation of the need of the intervention is insufficient. To facilitate PSO as a justified performance, the preparation of an interprofessional guideline is recommended.
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Affiliation(s)
| | - Franziska Rabenschlag
- 2 Abteilung Entwicklung & Forschung Pflege, MTD, Soziale Arbeit Universitäre Psychiatrische Kliniken Basel
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6
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Browne G, Hurley J. Mental Health Nurses as therapists in a rehabilitation setting: A phenomenological study. Int J Ment Health Nurs 2018; 27:1109-1117. [PMID: 29243882 DOI: 10.1111/inm.12423] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2017] [Indexed: 10/18/2022]
Abstract
Mental Health Nurses have a long tradition of delivering talk-based interventions across a range of clinical settings. Despite this, Mental Health Nurses receive limited recognition of this contribution. This paper presents findings from a study that explored Mental Health Nurses' experience of delivering talk-based therapies in an inpatient rehabilitation setting. This study uses semistructured interviews and a phenomenological approach to explore eight Mental Health Nurses' experience. Themes emerging included that: mental health nursing is a talk-based therapy in its own right, talk-based therapy was part of everyday nursing care on the floor and integrated talk-based therapy enhanced recovery opportunities for consumers. However, a further theme was that there were tensions around providing talk-based therapy conflicted with other roles including unit management and the role of nurses in controlling challenging behaviours. This study found that Mental Health Nurses, in this setting, are offering talk-based therapy to the people they care for. The findings of this study have implications for research: there needs to be a larger study investigating nurses' use of talk-based therapy in inpatient settings. If, as the authors expect that, it is found that mental health nurses are offering these therapies generally in inpatient settings, this has serious implications for postgraduate education in Mental Health Nursing policy in terms of recognition that this is happening and finding ways to support nurses to do this well. There also needs to be further research in the best ways to offer talk-based therapy in these settings.
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Affiliation(s)
- Graeme Browne
- School of Nursing & Midwifery, The University of Newcastle Port Macquarie, Port Macquarie, New South Wales, Australia
| | - John Hurley
- School of Health and Human Sciences, Southern Cross University, Coffs Harbour, New South Wales, Australia
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7
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Kuivalainen S, Vehviläinen-Julkunen K, Louheranta O, Putkonen A, Repo-Tiihonen E, Tiihonen J. De-escalation techniques used, and reasons for seclusion and restraint, in a forensic psychiatric hospital. Int J Ment Health Nurs 2017; 26:513-524. [PMID: 28960738 DOI: 10.1111/inm.12389] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2017] [Indexed: 11/28/2022]
Abstract
In Finland, the Mental Health Act determines the legal basis for seclusion and restraint. Restrictive measures are implemented to manage challenging situations and should be used as a last resort in psychiatric inpatient care. In the present study, we examined the reasons for seclusion and restraint, as well as whether any de-escalation techniques were used to help patients calm down. Seclusion and restraint files from a 4-year period (1 June 2009-31 May 2013) were retrospectively investigated and analysed by content analysis. Descriptive statistics were calculated. A total of 144 episodes of seclusion and restraint were included to analyse the reasons for seclusion and restraint, and 113 episodes were analysed to examine unsuccessful de-escalation techniques. The most commonly-used techniques were one-to-one interaction with a patient (n = 74, 65.5% of n = 113) and administration of extra medication (n = 37, 32.7% of n = 113). The reasons for seclusion and restraint were threatening harmful behaviour (n = 51, 35.4% of n = 144), direct harmful behaviour (n = 43, 29.9%), indirect harmful behaviour (n = 42, 29.1%), and other behaviours (n = 8, 5.6%). In general, the same de-escalation techniques were used with most patients. Most episodes of seclusion or restraint were due to threats of violence or direct violence. Individual means of self-regulation and patient guidance on these techniques are needed. Additionally, staff should be educated on a diverse range of de-escalation techniques. Future studies should focus on examining de-escalation techniques for the prevention of seclusion.
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Affiliation(s)
- Satu Kuivalainen
- Department of Forensic Psychiatry, University of Eastern Finland, Kuopio, Finland
| | | | - Olavi Louheranta
- Department of Forensic Psychiatry, University of Eastern Finland, Kuopio, Finland
| | - Anu Putkonen
- Department of Forensic Psychiatry, University of Eastern Finland, Kuopio, Finland
| | - Eila Repo-Tiihonen
- Department of Forensic Psychiatry, University of Eastern Finland, Kuopio, Finland
| | - Jari Tiihonen
- Department of Forensic Psychiatry, University of Eastern Finland, Kuopio, Finland.,National Institute for Health and Welfare, Helsinki, Finland.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Bowers L, Cullen AE, Achilla E, Baker J, Khondoker M, Koeser L, Moylan L, Pettit S, Quirk A, Sethi F, Stewart D, McCrone P, Tulloch AD. Seclusion and Psychiatric Intensive Care Evaluation Study (SPICES): combined qualitative and quantitative approaches to the uses and outcomes of coercive practices in mental health services. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05210] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundSeclusion (the isolation of a patient in a locked room) and transfer to a psychiatric intensive care unit (PICU; a specialised higher-security ward with higher staffing levels) are two common methods for the management of disturbed patient behaviour within acute psychiatric hospitals. Some hospitals do not have seclusion rooms or easy access to an on-site PICU. It is not known how these differences affect patient management and outcomes.ObjectivesTo (1) assess the factors associated with the use of seclusion and PICU care, (2) estimate the consequences of the use of these on subsequent violence and costs (study 1) and (3) describe differences in the management of disturbed patient behaviour related to differential availability (study 2).DesignThe electronic patient record system at one trust was used to compare outcomes for patients who were and were not subject to seclusion or a PICU, controlling for variables, including recent behaviours. A cost-effectiveness analysis was performed (study 1). Nursing staff at eight hospitals with differing access to seclusion and a PICU completed attitudinal measures, a video test on restraint-use timing and an interview about the escalation pathway for the management of disturbed behaviour at their hospital. Analyses examined how results differed by access to PICU and seclusion (study 2).ParticipantsPatients on acute wards or PICUs in one NHS trust during the period 2008–13 (study 1) and nursing staff at eight randomly selected hospitals in England, with varying access to seclusion and to a PICU (study 2).Main outcome measuresAggression, violence and cost (study 1), and utilisation, speed of use and attitudes to the full range of containment methods (study 2).ResultsPatients subject to seclusion or held in a PICU were more likely than those who were not to be aggressive afterwards, and costs of care were higher, but this was probably because of selection bias. We could not derive satisfactory estimates of the causal effect of either intervention, but it appeared that it would be feasible to do so for seclusion based on an enriched sample of untreated controls (study 1). Hospitals without seclusion rooms used more rapid tranquillisation, nursing of the patient in a side room accompanied by staff and seclusion using an ordinary room (study 2). Staff at hospitals without seclusion rated it as less acceptable and were slower to initiate manual restraint. Hospitals without an on-site PICU used more seclusion, de-escalation and within-eyesight observation.LimitationsOfficial record systems may be subject to recording biases and crucial variables may not be recorded (study 1). Interviews were complex, difficult, constrained by the need for standardisation and collected in small numbers at each hospital (study 2).ConclusionsClosing seclusion rooms and/or restricting PICU access does not appear to reduce the overall levels of containment, as substitution of other methods occurs. Services considering expanding access to seclusion or to a PICU should do so with caution. More evaluative research using stronger designs is required.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Len Bowers
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Alexis E Cullen
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Evanthia Achilla
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - John Baker
- School of Healthcare, University of Leeds, Leeds, UK
| | - Mizanur Khondoker
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Leonardo Koeser
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Lois Moylan
- Department of Nursing, Molloy College, Rockville, NY, USA
| | - Sophie Pettit
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Alan Quirk
- Royal College of Psychiatrists, London, UK
| | - Faisil Sethi
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Duncan Stewart
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Paul McCrone
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Alex D Tulloch
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
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9
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Slemon A, Jenkins E, Bungay V. Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice. Nurs Inq 2017; 24. [PMID: 28421661 PMCID: PMC5655749 DOI: 10.1111/nin.12199] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2017] [Indexed: 11/26/2022]
Abstract
The discourse of safety has informed the care of individuals with mental illness through institutionalization and into modern psychiatric nursing practices. Confinement arose from safety: out of both societal stigma and fear for public safety, as well as benevolently paternalistic aims to protect individuals from self‐harm. In this paper, we argue that within current psychiatric inpatient environments, safety is maintained as the predominant value, and risk management is the cornerstone of nursing care. Practices that accord with this value are legitimized and perpetuated through the safety discourse, despite evidence refuting their efficacy, and patient perspectives demonstrating harm. To illustrate this growing concern in mental health nursing care, we provide four exemplars of risk management strategies utilized in psychiatric inpatient settings: close observations, seclusion, door locking and defensive nursing practice. The use of these strategies demonstrates the necessity to shift perspectives on safety and risk in nursing care. We suggest that to re‐centre meaningful support and treatment of clients, nurses should provide individualized, flexible care that incorporates safety measures while also fundamentally re‐evaluating the risk management culture that gives rise to and legitimizes harmful practices.
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Affiliation(s)
- Allie Slemon
- School of Nursing, University of British Columbia (UBC), Vancouver, British Columbia, Canada
| | - Emily Jenkins
- School of Nursing, University of British Columbia (UBC), Vancouver, British Columbia, Canada
| | - Vicky Bungay
- School of Nursing, University of British Columbia (UBC), Vancouver, British Columbia, Canada
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10
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Sandy PT. The use of observation on patients who self-harm: Lessons from a learning disability service. Health SA 2016. [DOI: 10.1016/j.hsag.2016.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Schroeder R. Bearing Witness: The Lived Experience of Sitting With Patients. Arch Psychiatr Nurs 2016; 30:678-684. [PMID: 27888959 DOI: 10.1016/j.apnu.2016.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 02/23/2016] [Accepted: 03/18/2016] [Indexed: 10/22/2022]
Abstract
There is abundant literature focused on the practice of using hospital sitters as part of standard patient safety care. However, minimal attention has been paid to understanding the actual experiences of hospital workers as they sit with distressed and often agitated patients. With the overwhelming number of hospitalized patients who require sitters, attention must be paid to the healthcare workers' perspective. In this study a phenomenological approach was used to elicit the perceptions of these hospital sitters. Themes which emerged from the participant's lived experiences of sitting included: Accepting them, It's not about me, You're not alone, Taking it to heart, Lifts me up, and Supporting role, with an overarching focus of Bearing witness. Nursing implications for this study suggest that using advanced practice psychiatric nurses in med-surg settings may help to support the hiring and training of skilled sitters and lead to improved psychological nursing care. In addition, identifying health care workers who best "fit" the sitter profile may promote the role from one of safety surveillance to one of therapeutic engagement.
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12
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Bowers L, Alexander J, Bilgin H, Botha M, Dack C, James K, Jarrett M, Jeffery D, Nijman H, Owiti JA, Papadopoulos C, Ross J, Wright S, Stewart D. Safewards: the empirical basis of the model and a critical appraisal. J Psychiatr Ment Health Nurs 2014; 21:354-64. [PMID: 24460906 PMCID: PMC4237197 DOI: 10.1111/jpm.12085] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2013] [Indexed: 12/02/2022]
Abstract
ACCESSIBLE SUMMARY In the previous paper we described a model explaining differences in rates of conflict and containment between wards, grouping causal factors into six domains: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. This paper reviews and evaluates the evidence for the model from previously published research. The model is supported, but the evidence is not very strong. More research using more rigorous methods is required in order to confirm or improve this model. ABSTRACT In a previous paper, we described a proposed model explaining differences in rates of conflict (aggression, absconding, self-harm, etc.) and containment (seclusion, special observation, manual restraint, etc.). The Safewards Model identified six originating domains as sources of conflict and containment: the patient community, patient characteristics, the regulatory framework, the staff team, the physical environment, and outside hospital. In this paper, we assemble the evidence underpinning the inclusion of these six domains, drawing upon a wide ranging review of the literature across all conflict and containment items; our own programme of research; and reasoned thinking. There is good evidence that the six domains are important in conflict and containment generation. Specific claims about single items within those domains are more difficult to support with convincing evidence, although the weight of evidence does vary between items and between different types of conflict behaviour or containment method. The Safewards Model is supported by the evidence, but that evidence is not particularly strong. There is a dearth of rigorous outcome studies and trials in this area, and an excess of descriptive studies. The model allows the generation of a number of different interventions in order to reduce rates of conflict and containment, and properly conducted trials are now needed to test its validity.
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Affiliation(s)
- L Bowers
- Section of Mental Health Nursing, Institute of Psychiatry, Kings College London, London, UK
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Abstract
AIMS AND OBJECTIVES To describe the types and frequency of conflict behaviours exhibited by patients during the first 2 weeks of admission to acute psychiatric units, the methods staff use to manage them and bring to the surface underlying common patterns. BACKGROUND Many studies have investigated the prevalence and impact of psychiatric inpatient aggression. Much of the research to date has studied conflict and containment behaviours separately; however, some studies have reported relationships between certain behaviours suggesting that there are complex causal links between conflict and containment behaviours. DESIGN A cross-sectional survey of conflict and containment events. METHODS Nursing notes were accessed for 522 patients during the first 2 weeks of admission, in 84 wards in 31 hospitals in the South East of England. Conflict and containment events occurring during this period were recorded retrospectively. RESULTS Factor analysis revealed six patterns of conflict behaviour, which were related to containment methods and patient demographic factors. These factors confirm some previously reported patterns of conflict. CONCLUSIONS This study brings to light underlying common patterns of disruptive behaviour by psychiatric inpatients. The reasons for these remain obscure, but may relate to (1) national variations in policy and practice shaping static structural differences of interest between patients and staff and (2) normal developmental age and gender-specific behaviours. RELEVANCE TO CLINICAL PRACTICE Conflict behaviour patterns may be differently motivated and therefore require different management strategies by staff. There is a need for awareness by clinical staff to the fact that different types of conflict behaviours may be co-occurring or indicative of each other. Clinical staff should consider that implementation of and changes to hospital policies have the potential to change the nature and frequencies of certain conflict behaviours by patients.
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Affiliation(s)
- Jamie Ross
- e-Health Unit, UCL Research Department of Primary Care & Population Health, Upper 3rd Floor, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, UK.
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Learning from prevented suicide in psychiatric inpatient care: An analysis of data from the National Patient Safety Agency. Int J Nurs Stud 2011; 48:1459-65. [DOI: 10.1016/j.ijnurstu.2011.05.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Revised: 05/12/2011] [Accepted: 05/19/2011] [Indexed: 11/18/2022]
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