The effects of a nationwide program to reduce seclusion in the Netherlands

Safety hazards in patient seclusion events in psychiatric care: A video observation study

WHAT IS KNOWN ON THE SUBJECT?: Coercive measures such as seclusion are used to maintain the safety of patients and others in psychiatric care. The use of coercive measures can lead to harm among patients and staff. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study is the first of its kind to rely on video observation to expose safety hazards in seclusion events that have not been reported previously in the literature. The actions that both patients and staff take during seclusion events can result in various safety hazards. IMPLICATIONS FOR PRACTICE?: Constant monitoring of patients during seclusion is important for identifying safety hazards and intervening to prevent harm. Nursing staff who use seclusion need to be aware of how their actions can contribute to safety hazards and how they can minimize their potential for harm ABSTRACT: Introduction Seclusion is used to maintain safety in psychiatric care. There is still a lack of knowledge on potential safety hazards related to seclusion practices. Aim To identify safety hazards that might jeopardize the safety of patients and staff in seclusion events in psychiatric hospital care. Method A descriptive design with non-participant video observation was used. The data consisted of 36 video recordings, analysed with inductive thematic analysis. Results Safety hazards were related to patient and staff actions. Patient actions included aggressive behaviour, precarious movements, escaping, falling, contamination and preventing visibility. Staff actions included leaving hazardous items in a seclusion room, unsafe administration of medication, unsecured use of restraints and precarious movements and postures. Discussion This is the first observational study to identify safety hazards in seclusion, which may jeopardize the safety of patients and staff. These hazards were related to the actions of patients and staff. Implications for Practice Being better aware of possible safety hazards could help prevent adverse events during patient seclusion events. It is therefore necessary that nursing staff are aware of how their actions might impact their safety and the safety of the patients. Video observation is a useful method for identifying safety hazards. However, its use requires effort to safeguard the privacy and confidentiality of those included in the videos.

The Compulsory Care Act: Early Observations and Expectations of In- or Outpatient Involuntary Treatment

BACKGROUND

On January 1, 2020, the Dutch Compulsory Care Act (WvGGZ) replaced the Special Admissions Act (BOPZ). While the old law only allowed compulsory treatment in hospitals, the new law allows it both inside and outside the hospital. Moreover, the new law prioritizes the patient's own opinion on coercive measures. By following patients' own choices, the Compulsory Care Act is hoped to lead to fewer admission days and less inpatient compulsory treatment in involuntarily admitted patients.

METHODS

We studied the seclusion and enforced-medication events before and after January 1, 2020, using coercive measures monitoring data in a Mental Health Trust. Trends in hours of seclusion and the number of enforced-medication events per month from 2012 to 2019 were compared with 2020. We used generalized linear models to perform time series analysis. Logistic regression analyses and generalized linear models were performed to investigate whether patient compilation determined some of the observed changes in seclusion use or enforced-medication events.

RESULTS

The mean number of hours of seclusion between 2012 and 2019 was 27,124 per year, decreasing from 48,542 in 2012 to 21,133 in 2019 to 3,844 h in 2020. The mean incidence of enforced-medication events between 2012 and 2019 was 167, increasing from 90 in 2012 to 361 in 2019 and then fell to 294 in 2020. In 2020, we observed 3,844 h of seclusion and 294 enforced-medication events. Near to no outpatient coercion was reported, even though it was warranted. The time series analysis showed a significant effect of the year 2020 on seclusion hours (β = -1.867; Exp(β) = 0.155, Wald = 27.22, p = 0.001), but not on enforced-medication events [β = 0.48; Exp(β) = 1.616, Wald = 2.33, p = 0.13].

DISCUSSION

There was a reduction in the number of seclusion hours after the introduction of the Compulsory Care Act. The number of enforced-medication events also increased from a very low baseline, but from 2017 onwards. To see whether these findings are consistent over time, they need to be replicated in the near future.

CONCLUSION

We observed a significant increase in enforced-medication use and a decrease in seclusion hours. The year 2020 predicted seclusion hours, but not enforced-medication events.

Number of Seclusions in the Netherlands Higher in the 7 Years Since the End of a Nationwide Seclusion-Reduction Program

Introduction: Between 2006 and 2012 the Dutch government funded a nationwide program for reducing the use of seclusion. Although an initial first trend study showed that the reported number of seclusions declined during the program, the objective of a 10% annual decrease was not met. We wished to establish whether the decline had continued after funding ended in 2012. Method: Using quasi Poisson time series modeling, we retrospectively analyzed the nationally reported numbers of seclusion and involuntary medication between 1998 and 2019, i.e., before, during and after the end of the nationwide program, with and without correction for the number of involuntary admissions. Results: With and without correction for the number of involuntary admissions, there were more seclusions in the seven years after the nationwide program than during the nationwide program. Although the reported number of involuntary medications also increased, the rate of increase was slower after the end of the nationwide program than before. Conclusions: Rather than continuing to decrease after the end of the nationwide program, the number of seclusions rose. This may mean that interventions intended to reduce the use of seclusion within this program are not properly sustained in daily clinical care without an ongoing national program.

Does high and intensive care reduce coercion? Association of HIC model fidelity to seclusion use in the Netherlands

BACKGROUND

A new inpatient care model has been developed in the Netherlands: High and Intensive Care (HIC). The purpose of HIC is to improve quality of inpatient mental healthcare and to reduce coercion.

METHODS

In 2014, audits were held at 32 closed acute admission wards for adult patients throughout the Netherlands. The audits were done by trained auditors, who were professionals of the participating institutes, using the HIC monitor, a model fidelity scale to assess implementation of the HIC model. The HIC model fidelity scale (67 items) encompasses 11 domains including for example team structure, team processes, diagnostics and treatment, and building environment. Data on seclusion and forced medication was collected using the Argus rating scale. The association between HIC monitor scores and the use of seclusion and forced medication was analyzed, corrected for patient characteristics.

RESULTS

Results showed that wards having a relatively high HIC monitor total score, indicating a high level of implementation of the model as compared to wards scoring lower on the monitor, had lower seclusion hours per admission hours (2.58 versus 4.20) and less forced medication events per admission days (0.0162 versus 0.0207). The HIC model fidelity scores explained 27% of the variance in seclusion rates (p < 0.001). Adding patient characteristics to HIC items in the regression model showed an increase of the explained variance to 40%.

CONCLUSIONS

This study showed that higher HIC model fidelity was associated with less seclusion and less forced medication at acute closed psychiatric wards in the Netherlands.

Three Pathways of Seclusion Reduction Programs to Sustainability: Ten Years Follow Up in Psychiatry

From 2004 onwards, above 50 seclusion reduction programs (SRP) were developed, implemented and evaluated in the Netherlands. However, little is known about their sustainability, as to which extent obtained reduction could be maintained. This study monitored three programs over ten years seeking to identify important factors contributing to this. We reviewed documents of three SRPs that received governmental funding to reduce seclusion. Next, we interviewed key figures from each institute, to investigate the SRP documents and their implementation in practice. We monitored the number of seclusion events and the number of seclusion days with the Argus rating scale over ten years in three separate phases: 2008-2010, 2011-2014 and 2015-2017. As we were interested in sustainability after the governmental funding ended in 2012, our focus was on the last phase. Although in different rate, all mental health institutes showed some decline in seclusion events during and immediately after the SRP. After end of funding one institute showed numbers going up and down. The second showed an increase in number of seclusion days. The third institute displayed a sustained and continuous reduction in use of seclusion, even several years after the received funding. This institute was the only one with an ongoing institutional SRP after the governmental funding. To sustain accomplished seclusion reduction, a continuous effort is needed for institutional awareness of the use of seclusion, even after successful implementation of SRPs. If not, successful SRPs implemented in psychiatry will easily relapse in traditional use of seclusion.

Preventing and reducing 'coercion' in mental health services: an international scoping review of English-language studies

This article discusses initiatives aimed at preventing and reducing 'coercive practices' in mental health and community settings worldwide, including in hospitals in high-income countries, and in family homes and rural communities in low- and middle-income countries. The article provides a scoping review of the current state of English-language empirical research. It identifies several promising opportunities for improving responses that promote support based on individuals' rights, will and preferences. It also points out several gaps in research and practice (including, importantly, a gap in reviews of non-English-language studies). Overall, many studies suggest that efforts to prevent and reduce coercion appear to be effective. However, no jurisdiction appears to have combined the full suite of laws, policies and practices which are available, and which taken together might further the goal of eliminating coercion.

International research into 22 years of use of chemical restraint: An evidence overview

BACKGROUND

Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non-consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice.

AIMS

To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995.

METHODS

This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures.

RESULTS

This review identified 311 relevant primary studies (21 RCTs; 46 non-controlled experimental or prospective observational studies; 77 cross-sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross-country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%).

DISCUSSION

A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non-consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non-chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research.

Increased use of coercive procedures and prolonged hospitalization in compulsory admitted psychotic patients, who refuse antipsychotic medication

Objective: Current Danish legislation imposes that compulsory admitted psychotic patients have the right to refuse antipsychotic medication, which markedly delays pertinent medical treatment.Material and methods: In a retrospective, observational cohort study, we analyzed data from a 1-year period on 34 consecutively admitted patients with schizophrenia, who had been compulsory admitted due to need of treatment, or because they were judged to constitute an acute danger to themselves or others. We compared the use of other coercive procedures and hospitalization time.Results: Twenty-three patients accepted to commence antipsychotic treatment immediately, and 11 patients submitted an official complaint, which significantly delayed initiation of antipsychotic treatment (1 day ±0.9 versus 14 days ±10.1, p = 0.002). The 11 complaining patients were subjected to 6.8 times more coercive procedures of forced sedative medication compared to the 23 patients without delay (2.7 ± 2.3 episodes versus 0.4 ± 0.7 episodes, p = 0.007). Moreover, the treatment-delay prolonged duration of hospitalization by a factor 2.3 (73.3 ± 28.3 days versus 31.7 ± 22.0 days, p < 0.001).Conclusion: The current legislation intends to preserve patient rights and promote voluntary treatment alliance but may instead lead to prolonged hospitalization and increased use of other coercive measures such as forced sedative medication. Modification of current legislation may therefore be considered.

Commentary: seclusion and mechanical restraint of psychiatric patients in Israel - an update

Recently, Miodownik et al. reported in this journal the results of a study on seclusion and mechanical restraint of psychiatric patients in Israel (Isr J Health Policy Res 8:9, 2019). The study was a retrospective examination over a year of one inpatient ward in a psychiatric hospital. They found negative associations between length of use of coercive measures and the diagnosis of schizophrenia, being single, and the presence of academic nurses. Positive associations were found between length of use of coercive measures and the use of antipsychotic medications, violence towards oneself, and the use of restraint compared to seclusion. Interesting and important as they are, these results were obtained from data gathered in 2014. As the authors note, since then there has been a dramatic change in the official policy of the Israeli Ministry of Health on this topic and in the practice of seclusion and mechanical restraint in Israel. This commentary reviews and comments on the current situation.

"But I did not touch nobody!"-Patients' and nurses' perspectives and recommendations after aggression on psychiatric wards-A qualitative study

AIMS

To gain a deeper understanding of the differences in patients and staff perspectives in response to aggression and to explore recommendations on prevention.

DESIGN

Qualitative, grounded theory study.

METHODS

We conducted semi-structured interviews with patients and nurses involved in an aggressive incident. Data collection was performed from May 2016 - March 2017.

RESULTS

Thirty-one interviews were conducted concerning 15 aggressive incidents. Patients and nurses generally showed agreement on the factual course of events, there was variation in agreement on the perceived severity (PS). Patients' recommendations on prevention were mostly personally focussed, while nurses suggested general improvements.

CONCLUSION

Patients are often capable to evaluate aggression and give recommendations on prevention shortly after the incident. Patients and nurses differ in the PS of aggression. Recommendations on prevention of patients and nurses are complementary.

IMPACT

What problem did the study address? Perspectives of patients and nurses differ with respect to aggression, but how is unclear. What were the main findings? Patients and nurses generally described a similar factual course of events concerning the incident, patients often perceive the severity less than nurses. Patients are capable to give recommendations on prevention of aggressive incidents, shortly after the incident. Where and on whom will the research have impact? Factual course of events can be a common ground to start evaluating aggressive incidents and post-incident review should address the severity of incidents. Asking recommendations from patients on how to improve safety and de-escalation can lead to innovative and personal de-escalation strategies and supports patients autonomy.

Reflecting on the Reasons Pros and Cons Coercive Measures for Patients in Psychiatric and Somatic Care: The Role of Clinical Ethics Consultation. A Pilot Study

Background and aim: Coercive measures in patient care have come under criticism leading to implement guidelines dedicated to the reduction of coercion. This development of bringing to light clinical ethics support is hoped to serve as a means of building up awareness and potentially reducing the use of coercion. This study explores the specific features of ethics consultation (EC) while dealing with coercion. Material and method: Basel EC documentation presents insight to all persons involved with a case. The EC database of two Basel university hospitals was developed on the grounds of systematic screening and categorization by two reviewers. One hundred fully documented EC cases databased from 2013 to 2016 were screened for the discussion of coercive measures (somatic hospital and psychiatry: 50% cases). Results: Twenty-four out of 100 EC cases addressed coercion in relation to a clinically relevant question, such as compulsory treatment (70.8%), involuntary committal (50%), or restricting liberty (16.6%). Only 58.3% of EC requests mentioned coercion as an ethical issue prior to the meeting. In no case was patient decisional capacity given, capacity was impaired (43.5%), not given (33.3%), or unclear (21.7%; one not available). Discussion: As clinical staff appears sensitive to perceiving ethical uncertainty or conflict, but less prepared to articulate ethical concern, EC meetings serve to "diagnose" and "solve" the ethical focus of the problem(s) presented in EC. Patient decisional incapacity proved to be an important part of reasoning, when discussing the principle of harm prevention. While professional judgment of capacity remains unsystematic, rationality or even ethicality of decision making will be hampered. The documented EC cases show a variety of decisions about whether or not coercion was actually applied. Ethical reasoning on the competing options seemed to be instrumental for an unprejudiced decision complying with the normative framework and for building a robust consensus. Conclusions: The recommendation is whether EC should be used as a standard practice whenever coercion is an issue-ideally before coercion is applied, or otherwise. Moreover, more efforts should be made toward early and professional assessment of patient capacity and advance care counseling including the offer of advance directives.

Text Analysis of Electronic Medical Records to Predict Seclusion in Psychiatric Wards: Proof of Concept

Aim: With the introduction of "Electronic Medical Record" (EMR) a wealth of digital data has become available. This provides a unique opportunity for exploring precedents for seclusion. This study explored the feasibility of text mining analysis in the EMR to eventually help reduce the use of seclusion in psychiatry. Methods: The texts in notes and reports of the EMR during 5 years on an acute and non-acute psychiatric ward were analyzed using a text mining application. A period of 14 days was selected before seclusion or for non-secluded patients, before discharge. The resulting concepts were analyzed using chi-square tests to assess which concepts had a significant higher or lower frequency than expected in the "seclusion" and "non-seclusion" categories. Results: Text mining led to an overview of 1,500 meaningful concepts. In the 14 day period prior to the event, 115 of these concepts had a significantly higher frequency in the seclusion category and 49 in the non-seclusion category. Analysis of the concepts from days 14 to 7 resulted in 54 concepts with a significantly higher frequency in the seclusion-category and 14 in the non-seclusion category. Conclusions: The resulting significant concepts are comparable to reasons for seclusion in literature. These results are "proof of concept". Analyzing text of reports in the EMR seems therefore promising as contribution to tools available for the prediction of seclusion. The next step is to build, train and test a model, before text mining can be part of an evidence-based clinical decision making tool.

Long-Term Impact of a Tailored Seclusion Reduction Program: Evidence for Change?

International comparative studies show that Dutch seclusion rates are relatively high. Therefore, several programs to change this practice were developed and implemented. The purpose of this study was to examine the impact of a seclusion reduction program over a long time frame, from 2004 until 2013. Three phases could be identified; the phase of development and implementation of the program (2004-2007), the project phase (2008-2010) and the consolidation phase (2011-2013). Five inpatient wards of a mental health institute were monitored. Each ward had one or more seclusion rooms. Primary outcome were the number and the duration of seclusion incidents. Involuntary medication was monitored as well to rule out substitution of one coercive measure by another. Case mix correction for patient characteristics was done by a multi-level logistic regression analysis with patient characteristics as predictors and hours seclusion per admission hours as outcome. Seclusion use reduced significantly during the project phase, both in number (-73%) and duration (-80%) and was not substituted by the use of enforced medication. Patient compilation as analyzed by the multi- level regression seemed not to confound the findings. Findings show a slight increase in number and seclusion days over the last year of monitoring. Whether this should be interpreted as a continuous or temporary trend remains unclear and is subject for further investigation.

Associations between psychiatric symptoms and seclusion use: Clinical implications for care planning

Findings from an increasing number of studies suggest that incorporating systematic short-term risk assessments in treatment planning could lead to safer practice on psychiatric admissions wards. The aim of the present study was to investigate the associations between the scores of three structured observation tools - the Kennedy Axis V (K-Axis-V), the Brief Psychiatric Rating Scale (BPRS), and the Social Dysfunction and Aggression Scale (SDAS) - and seclusion. In total, 1840 weekly risk assessments with these observation scales were collected over 2342 admission weeks. These assessment scores related to 370 acutely-admitted psychiatric patients and were subjected to a multilevel analysis. It was found that several dynamic and static factors were related to seclusion. Dynamic factors included violent behaviour, current substance abuse, suspiciousness, and negativism. Static factors included ethnicity and having been diagnosed with a substance abuse disorder. The findings suggest that the incorporation of the Kennedy-Axis V, the BPRS, and the SDAS into standard practice might be helpful in identifying patients at high risk of seclusion, and could be supportive to treatment planning and clinical decision-making in the prevention of seclusion use in acute psychiatric settings.

Study protocol for a cluster randomised controlled trial to assess the effectiveness of user-driven intervention to prevent aggressive events in psychiatric services

BACKGROUND

People admitted to psychiatric hospitals with a diagnosis of schizophrenia may display behavioural problems. These may require management approaches such as use of coercive practices, which impact the well-being of staff members, visiting families and friends, peers, as well as patients themselves. Studies have proposed that not only patients' conditions, but also treatment environment and ward culture may affect patients' behaviour. Seclusion and restraint could possibly be prevented with staff education about user-centred, more humane approaches. Staff education could also increase collaboration between patients, family members and staff, which may further positively affect treatment culture and lower the need for using coercive treatment methods.

METHODS

This is a single-blind, two-arm cluster randomised controlled trial involving 28 psychiatric hospital wards across Finland. Units will be randomised to receive either a staff educational programme delivered by the team of researchers, or standard care. The primary outcome is the incidence of use of patient seclusion rooms, assessed from the local/national health registers. Secondary outcomes include use of other coercive methods (limb restraint, forced injection, and physical restraint), service use, treatment satisfaction, general functioning among patients, and team climate and employee turn-over (nursing staff).

DISCUSSION

The study, designed in close collaboration with staff members, patients and their relatives, will provide evidence for a co-operative and user-centred educational intervention aiming to decrease the prevalence of coercive methods and service use in the units, increase the functional status of patients and improve team climate in the units. We have identified no similar trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02724748 . Registered on 25th of April 2016.

Interventions following a high violence risk assessment score: a naturalistic study on a Finnish psychiatric admission ward

BACKGROUND

Patient aggression and violence against staff members and other patients are common concerns in psychiatric units. Many structured clinical risk assessment tools have recently been developed. Despite their superiority to unaided clinical judgments, staff has shown ambivalent views towards them. A constant worry of staff is that the results of risk assessments would not be used. The aims of the present study were to investigate what were the interventions applied by the staff of a psychiatric admission ward after a high risk patient had been identified, how frequently these interventions were used and how effective they were.

METHODS

The data were collected in a naturalistic setting during a 6-month period in a Finnish psychiatric admission ward with a total of 331 patients with a mean age of 42.9 years (SD 17.39) suffering mostly from mood, schizophrenia-related and substance use disorders. The total number of treatment days was 2399. The staff assessed the patients daily with the Dynamic Appraisal of Situational Aggression (DASA), which is a structured violence risk assessment considering the upcoming 24 h. The interventions in order to reduce the risk of violence following a high DASA total score (≥4) were collected from the patients' medical files. Inductive content analysis was used.

RESULTS

There were a total of 64 patients with 217 observations of high DASA total score. In 91.2% of cases, at least one intervention aiming to reduce the violence risk was used. Pro re nata (PRN)-medication, seclusion and focused discussions with a nurse were the most frequently used interventions. Non-coercive and non-pharmacological interventions like daily activities associated significantly with the decrease of perceived risk of violence.

CONCLUSION

In most cases, a high score in violence risk assessment led to interventions aiming to reduce the risk. Unfortunately, the most frequently used methods were psychopharmacological or coercive. It is hoped that the findings will encourage the staff to use their imagination when choosing violence risk reducing intervention techniques.

Seclusion and enforced medication in dealing with aggression: A prospective dynamic cohort study

BACKGROUND

In the Netherlands, seclusion is historically the measure of first choice in dealing with aggressive incidents. In 2010, the Mediant Mental Health Trust in Eastern Netherlands introduced a policy prioritising the use of enforced medication to manage aggressive incidents over seclusion. The main goal of the study was to investigate whether prioritising enforced medication over seclusion leads to a change of aggressive incidents and coercive measures.

METHODS

The study was carried out with data from 2764 patients admitted between 2007 and 2013 to the hospital locations of the Mediant Mental Health Trust in Eastern Netherlands, with a catchment area of 500,000 inhabitants. Seclusion, restraint and enforced medications as well as other coercive measures were gathered systematically. Aggressive incidents were assessed with the SOAS-R. An event sequence analysis was preformed, to assess the whether seclusion, restraint or enforced medication were used or not before or after aggressive incidents.

RESULTS

Enforced medication use went up by 363% from a very low baseline. There was a marked reduction of overall coercive measures by 44%. Seclusion hours went down by 62%. Aggression against staff or patients was reduced by 40%.

CONCLUSIONS

When dealing with aggression, prioritising medication significantly reduces other coercive measures and aggression against staff, while within principles of subsidiarity, proportionality and expediency.

The influence of dysfunctional impulsivity and alexithymia on aggressive behavior of psychiatric patients

Current approaches in Dutch mental health care institutions towards inpatients' aggression have focused predominantly on environmental factors, such as training the staff in aggression management. However, personality traits might be an important factor in patients' aggression - as shown by incidents in the wards. This study explores the influence of dysfunctional impulsivity and alexithymia on psychiatric patients' aggressive behavior, through self-reports and through involvement in aggressive incidents. Personality traits influencing patients' aggression emphasize the importance of a more direct approach to their aggression. Clinical patients at Dutch mental health care institution Emergis (n=84) filled out questionnaires about their aggressiveness (using Buss and Perry's Aggression Questionnaire Short Form), dysfunctional impulsivity and alexithymia. Multiple regression analyses indicated that dysfunctional impulsivity positively related to self-reported aggressive behavior. The relationship, however, could not be confirmed for inpatients' aggression as reported by the staff on the wards. Unexpectedly affective alexithymia negatively related to hostility. Gender differences in self-reported aggression were found. Female patients showed higher levels of hostility. Regression analyses indicated that the male gender positively related to physical aggression. Findings emphasize the importance of a new approach in Dutch mental health care, in which patients may engage in aggression-regulation training programs.

Comparison of restraint data from four countries

BACKGROUND

Previous studies comparing restraint data from different countries had to rely on randomly published data and showed wide variance in the prevalence of restraint between countries.

AIM

To systematically compare datasets from four similar European countries with regard to restraint prevalence.

METHODS

We analysed whole country or area datasets on restraint from Wales, Ireland, Germany and the Netherlands systematically, thus excluding selection, patient and setting bias. Learning disability (LD) and forensic settings were analysed separately. Differences in proportions between countries were tested by means of Chi square, with number of admissions, admission days and catchment area as denominator and counts of restraint as numerators.

RESULTS

Full datasets were obtained allowing calculations of total admissions, total restraint numbers, numbers of patients involved and total occupied bed days. Data for Ireland is from 2012 and from 2013 for the other three countries. The percentage of patients exposed to restraint varies between 4.5 and 9.4 %. The average number of restraints per patient is stable at around 3 in all countries. Patient numbers affected by restraint per 100 occupied bed days per month vary between 0.095 and 0.200. The Netherlands have the highest use of seclusion (79 %), the longest restraint times and low use of enforced medication. Wales the lowest use of seclusion (2 %), followed by Ireland (29 %) and Germany (49 %). Events per 100 admissions per month vary between 17 and 21. Patients affected by restraint per 100 admissions per month vary between 5.4 and 7.5. LD services account for a disproportionately high number of restraint events.

CONCLUSION

Patient related restraint data are remarkably similar between countries. Type and length of restraint still vary significantly.

One-year incidence and prevalence of seclusion: Dutch findings in an international perspective

BACKGROUND

The Netherlands started a nationwide coercion reduction program in 2007. In 2011, accurate registration of coercive measures became obligatory by law.

OBJECTIVE

The aim of this study was to compare number and duration of coercive measures in the Netherlands with international data.

METHODS

2011 data on coercive measures were collected, using a system developed in Germany. To understand determinants of coercion, multilevel logistic regression was performed.

RESULTS

12.0 % (n = 5169) of patients (n = 42.960) in 2011 experienced at least one coercive measure. Exposure to coercion was comparable to other countries, and duration was higher. Medication use seemed to half average times in seclusion. In the Netherlands, coercion mainly constituted of seclusion and occurred in bipolar and psychotic disorders. In Germany, coercion was mostly mechanical restraint and occurred in organic disorders and schizophrenia.

CONCLUSIONS

Gathering comprehensive data allows comparisons between countries, increasing our understanding of the impact of different cultures, legislation and health care systems on coercion. In the Netherlands, seclusion is still the main type of coercion, despite significant improvements in the last few years. It is shorter when applied in combination with enforced medication.

Nurses' attitudes towards professional containment methods used in psychiatric wards and perceptions of aggression in Turkey

AIMS AND OBJECTIVE

The aim of this study was to determine nurses' attitudes towards professional containment methods and to explore the relationship between those attitudes and nurses' perception of aggression.

BACKGROUND

Different containment methods are used in psychiatric wards when patients behave aggressively towards others or exhibit self-harm. It is known that in addition to patient-specific and environmental influences, many factors related to the staff influence the choice of containment method. One of these factors is the perception of aggression.

DESIGN

A cross-sectional descriptive design was used and the sample consisted of 144 nurses who are employed in a psychiatric hospital in Istanbul and who volunteered to participate in the study.

METHOD

Data were collected using a questionnaire addressing the socio-demographic and professional features of nurses and using the attitudes to professional containment methods and Perception of Aggression Scale.

RESULTS

While pro re nata medication was used commonly, time-out was infrequently used in the wards. Intermittent observation, pro re nata medication and containment in the psychiatric intensive care unit were the most approved methods. The use of net beds was the least approved method. Nurses who perceive aggression as dysfunctional/undesirable are more likely to approve compulsory intramuscular medication and mechanical restraint.

CONCLUSION

These results showed that nurses' perception of aggression is an important factor influencing the choice of a professional containment method.

RELEVANCE TO CLINICAL PRACTICE

This study might lead to closer critiquing of psychiatric ward nurses' attitudes towards professional containment methods, leading to a decrease in the usage of these methods.

Seclusion and the importance of contextual factors: An innovation project revisited

Variation in seclusion rates between psychiatric facilities cannot be adequately explained by patient characteristics alone and there is a growing awareness of the influence of 'cultural' and staff factors on the use of seclusion. In this study, staff variables as well as seclusion parameters were investigated during the implementation of an innovation project, against the background of an institutional program to reduce the use of coercive measures. The results demonstrate the impact of confidence within the team, staffing level and communication with the patient on nurses' decisions on seclusion. The importance of the organizational context is further illustrated by the negative effects of organizational instability on nurses' attitudes and decision making with respect to seclusion, and on seclusion rates. A reduction in the use of seclusion was achieved after the implementation of the innovation project; however, during a period of organizational turmoil, the work engagement scores of staff decreased and the use of seclusion increased. The results of this study show the vulnerability of innovations within the continuously changing organizational context of mental health care.

The use of coercive interventions in mental health care in Germany and the Netherlands. A comparison of the developments in two neighboring countries

In this review, we compare the use of coercion in mental health care in Germany and in the Netherlands. Legal frameworks and published data on involuntary commitment, involuntary medication, seclusion, and restraint are highlighted as well as the role of guidelines, training, and attitudes held by psychiatrists and the public. Legal procedures regulating involuntary admission and commitment are rather similar, and so is the percentage of involuntary admissions and the rate per 100,000 inhabitants. However, opposing trends can be observed in the use of coercive interventions during treatment, which in both countries are considered as a last resort after all other alternative approaches have failed. In the Netherlands, for a long time seclusion has been considered as preferred intervention while the use of medication by force was widely disapproved as being unnecessarily invasive. However, after increasing evidence showed that number and duration of seclusions as well as the number of aggressive incidents per admission were considerably higher than in other European countries, attitudes changed within recent years. A national program with spending of 15 million € was launched to reduce the use of seclusion, while the use of medication was facilitated. A legislation is scheduled, which will allow also outpatient coercive treatment. In Germany, the latter was never legalized. While coercive treatment in Germany was rather common for involuntarily committed patients and mechanical restraint was preferred to seclusion in most hospital as a containment measure, the decisions of the Constitutional Court in 2011 had a high impact on legislation, attitudes, and clinical practice. Though since 2013 coercive medication is approvable again under strict conditions, it is now widely perceived as very invasive and last resort. There is evidence that this change of attitudes lead to a considerable increase of the use of seclusion and restraint for some patients.

Does experienced seclusion or restraint affect psychiatric patients' subjective quality of life at discharge?

Background

In Finland major effort has been invested in reducing the use of coercion in psychiatric treatment, and the goal is to diminish the use of coercion by 40% by 2015. Improving patients’ quality of life (QoL) has gained prominence in psychiatric treatment during the past decade. Numerous studies have shown that most secluded or restrained patients (S/R patients) would prefer not to have had this experience. Experience of S/R could affect negatively patients’ QoL, but empirical data on this issue are lacking.

Aim

The study aimed to explore the effect of experienced S/R on the subjective QoL of psychiatric in-patients.

Method

This study explored subjective QoL of the S/R patients. At discharge, S/R patients completed the Short Form of the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF).

Results

We found that S/R patients’ (n = 36) subjective QoL was significantly better than that of non-S/R patients’ (n = 228). Most non-S/R patients were diagnosed with mood disorders (mostly depression). Most of S/R patients were diagnosed with schizophrenia, schizotypal and delusional disorders. The mean duration of S/R was 2.3 days, median was one day and mean length of the hospitalization after S/R episode was 2.5 months.

Conclusion

Our cross-sectional findings suggest that S/R does not considerably influence patients’ QoL or that the influence is short-lived. Because baseline QoL was not measured this remains uncertain. There are also many other factors, such as negative mood, which decrease the patients’ QoL ratings. These factors may either mask the influence of S/R on QoL or modify the experience of QoL to such an extent that no independent association can be found at the time of discharge.

[Compulsory treatment in psychiatry: an ethical analysis of the new legal regulations for clinical practice]

BACKGROUND

The new legal regulations of compulsory treatment in Germany require a change in clinical psychiatric practice as well as an ethical analysis of the consequences for those involved.

MATERIALS AND METHODS

The new legal regulations are reported and via ethical analysis new problematic fields, such as consequences of the new law are identified and discussed in the context of psychiatry and law.

RESULTS

The main ethical identified problems are care of mentally ill with mental competence who refuse medical treatment, the different normative assessment of compulsory treatment and mechanical fixation, the ambivalent role of the conversation between psychiatrist and patient in order to change the natural will of the patient to avoid compulsory measures, the ethical consequences of questionable financial incentives in the context of compulsory treatment and the contradictive legal regulations in the field.

CONCLUSIONS

The ethical analysis of the new law on compulsory treatment in Germany shows chances for improvement of clinical psychiatric practice as well as normative problematic regulations and fields of conflicts.