Protocols to reduce seclusion in inpatient mental health units

The use of seclusion to manage conflict behaviours in psychiatric inpatient settings is increasingly viewed as an intervention of last resort. Many protocols have, thus, been developed to reduce the practice. We conducted a systematic review to determine the effectiveness of protocols to reduce seclusion on process outcomes (e.g., seclusion, restraint), patient outcomes (e.g., injuries, aggressive incidents, satisfaction), and staff outcomes (e.g., injuries, satisfaction). We searched Medline, Embase, the Cochrane Register of Clinical Trials, PsycINFO, CINAHL, cairn.info, and ClinicalTrials.gov for protocols to reduce seclusion practices for adult patients on inpatient mental health units (from inception to September 6, 2022). We summarised and categorised reported elements of the protocols designed to reduce seclusion using the Behaviour Change Wheel Intervention Functions and resources needed to implement the protocol in psychiatric units. We assessed risk of bias and determined certainty of evidence using GRADE. Forty-eight reports addressed five approaches to reduce seclusion: hospital/unit restructuring (N = 4), staff education/training (N = 3), sensory modulation rooms (N = 7), risk assessment and management protocols (N = 7), and comprehensive/mixed interventions (N = 22; N = 6 without empirical data). The relationship between the various protocols and outcomes was mixed. Psychiatric units that implement architecturally positive designs, sensory rooms, the Brøset Violence Checklist, and various multi-component comprehensive interventions may reduce seclusion events, though our certainty in these findings is low due to studies' methodological limitations. Future research and practice may benefit from standardised reporting of process and outcome measures and analyses that account for confounders.

Art therapy is associated with a reduction in restrictive practices on an inpatient child and adolescent mental health unit

BACKGROUND

The elimination of restrictive practices, such as seclusion and restraint, is a major aim of mental health services globally. The role of art therapy, a predominantly non-verbal mode of creative expression, is under-explored in this context. This research aimed to determine whether art therapy service provision was associated with a reduction in restrictive practices on an acute inpatient child and adolescent mental health services (CAMHS) unit.

METHODS

The rate (events per 1,000 occupied bed days), frequency (percent of admitted care episodes with incident), duration, and number of incidents of restrictive practices occurring between July 2015 and December 2021 were analysed relative to art therapy service provision. The rate, frequency and number of incidents of intramuscular injected (IM) sedation, oral PRN (as-needed medication) use, and absconding incidents occurring in conjunction with an episode of seclusion or restraint were also analysed.

RESULTS

The rate, frequency, duration, and total number of incidents of seclusion, the frequency and total number of incidents of physical restraint, and the rate, frequency and total number of incidents of IM sedation showed a statistically significant reduction during phases of art therapy service provision.

CONCLUSIONS

Art therapy service provision is associated with a reduction in restrictive practices in inpatient CAMHS.

Women's experiences of restrictive interventions within inpatient mental health services: A qualitative investigation

Restrictive interventions (RI), such as physical restraint, seclusion, and rapid tranquilization, can have negative psychological effects on service users; however, there has been little investigation regarding their effects on women. The aim of this paper was to explore women's experiences of RI within UK inpatient mental health services. Twenty women accessing inpatient mental health services participated in semi-structured interviews. Using thematic analysis (TA), three primary themes were reported from women's experiences: (1) powerlessness, (2) dehumanization, and (3) relationships and communication. Clinical recommendations included ensuring gender-awareness and trauma-informed care training is mandatory for all mental health staff, for RI training to include awareness of gender differences, and for policies to be reviewed with regard to women being invasively searched and ensuring sanitary products are safely available for women within seclusion. Directions for future research include investigating the experiences of RI for women from minority ethnic groups and exploring important moderators and mediators in the relationship between RI and re-traumatization for women.

Exploring the experience of acute inpatient mental health care from the perspective of family and carers of people experiencing psychosis: A qualitative thematic analysis study conducted during the COVID-19 pandemic

Family and carers play an important role in supporting service users who are in receipt of acute mental health inpatient care, but they can also be significantly emotionally and physically impacted. The aim of this study was to examine their needs and priorities during this time. Fourteen family and carers of inpatients experiencing psychosis completed semi-structured interviews examining their experiences of inpatient care during the COVID-19 pandemic. Thematic analysis was used to analyse data. Four key themes were identified: 'A turbulent journey to hospital admission', 'I need information and support', 'Maintaining my relationship with my loved one' and 'Inpatient care is a mixed bag'. Each theme comprised four or five subthemes. The findings demonstrated that family and carers feel excluded from inpatient care and struggled to maintain contact with their loved ones, which was exacerbated by COVID-19 related restrictions. Communication and being regularly informed about their loved one's care, as well as visiting loved ones, was particularly problematic. Inpatient care needs to be more inclusive of family and carers and ensure they are kept in mind at every stage of the admission.

'In some ways it all helps but in some ways it doesn't': The complexities of service users' experiences of inpatient mental health care in Australia

Recovery-oriented mental health care requires active involvement of service users in the evaluation of care. While experience of care surveys is routinely given out upon discharge, capturing the depth and detail of service users' experiences in such a way to meaningfully improve services may require more in-depth and targeted approaches. This study aimed to gather voluntary and involuntary service users' experiences of care during hospitalization in two acute adult mental health inpatient units, through the collaborative completion of a purpose designed tool. The purpose of the study was to examine broad experiences of care and to identify the utility of proactive approaches to ongoing service evaluation. Overall, 67 participants were interviewed. Findings highlight the complexity of experiences of care including how an admission can seemingly facilitate clinical recovery while not being recovery-oriented. The findings also detail areas for improvement in the way that care is delivered and evaluated. The implications are particularly pertinent for mental health nurses to consider how, within the existing constraints of their roles, they can provide therapeutic care to all service users.

A Model for Rounding With Patients in a Psychiatric Hospital

BACKGROUND

Hourly rounding is an organized practice where nurses perform regular checks on individual patients at fixed intervals in order to elicit any information that will improve the patient's care and well-being. Weaknesses in the existing literature on rounding include a lack of focus on the nurse-patient interaction, the absence of a guiding theoretical framework, and, lastly, marginal implementation of rounding within the psychiatric setting.

PURPOSE

The intent of this paper is to address these weaknesses by describing and proposing a rounding tool, based upon the acronym ICARE, to be used in the inpatient psychiatric setting. Roach's Theory on Caring will be the theoretical underpinnings for the basis of this rounding initiative.

PRACTICE IMPLICATIONS

It is the belief that the hourly rounding initiative will improve satisfaction and the overall quality of care for the psychiatric patient.

Trauma-informed care in inpatient mental health settings: a review of the literature

Trauma-informed care is an emerging value that is seen as fundamental to effective and contemporary mental health nursing practice. Trauma-informed care, like recovery, leaves mental health nurses struggling to translate these values into day-to-day nursing practice. Many are confused about what individual actions they can take to support these values. To date, the most clearly articulated policy to emerge from the trauma-informed care movement in Australia has been the agreement to reduce, and wherever possible, eliminate the use of seclusion and restraint. Confronted with the constant churn of admissions and readmissions of clients with challenging behaviours, and seemingly intractable mental illness, the elimination of seclusion and restraint is seen to be utopian by many mental health nurses in inpatient settings. Is trauma-informed care solely about eliminating seclusion and restraint, or are there other tangible practices nurses could utilize to effect better health outcomes for mental health clients, especially those with significant abuse histories? This article summarizes the findings from the literature from 2000-2011 in identifying those practices and clinical activities that have been implemented to effect trauma-informed care in inpatient mental health settings.