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Objective: This study assessed trends in use of seclusion and restraint in response to injurious assault, including trends in percentage of assaults involving seclusion or restraint; average duration of seclusion; average duration of restraint using devices and holds (physical restraint); and percentages of restraint episodes involving devices, medication, and holds.Methods: Monthly administrative data from 2007 to 2013 for 438 adult psychiatric units in 317 U.S. hospitals were aggregated to compute annual measures. Time trends were assessed with nonparametric tests.Results: There was little evidence suggesting a decline in the frequency with which seclusion and restraint are used, but there were decreasing trends in average duration of physical restraint and percentage of restraint episodes involving devices.Conclusions: Efforts to curb seclusion and restraint have apparently been successful in reducing use of devices in restraint and shortening restraint duration. There may be room for improvement in reducing duration of seclusion. [ABSTRACT FROM AUTHOR]

It is the sad reality that our prisons have become the new "institutions" for housing the severely mentally ill in the aftermath of the deinstitutionalization movement. Instead of compassionate medical treatment, these individuals are often isolated for long periods of time (seclusion) or tied down against their will (restraint) when they "fail to comply" with an order or "act out" in the corrections setting. Frequently, the very behavior triggering placement of mentally ill "prisoners" into prolonged and illegal seclusion and restraint is a manifestation of their illness(es), which is only exacerbated by the harsh conditions of confinement and a "corrections" environment, as opposed to a treatment- and rehabilitation-centered milieu. Indeed, they are often left without any medical superx'ision whatsoever, much less the minimally adequate treatment that the law requires. This Article explores emerging thought and the legal underpinnings for challenging the status quo of the failure to protect the basic civil rights of confined mentally ill individuals. When challenged or otherwise subject to scrutiny, deference given under the law to clinical decisions in the corrections setting regarding the care and treatment of confined mentally ill individuals should not amount to the complete abdication of jurisprudential responsibility for ensuring equal protection of the law to those who need the protections of our Constitution the most. When it comes to unjustified and prolonged seclusion and restraint of severely mentally ill individuals, the authors of this Article believe that the medical and clinical professionals currently enlisted to provide their services to such mentally ill prisoners should not be given any deference to order prolonged seclusion and restraint as part of their so-called "clinical" decisionmaking. [ABSTRACT FROM AUTHOR]

Psychiatrists in psychiatric hospitals or residential facilities can find themselves involved in patient crises that precipitate a restraint or seclusion. The decision to become directly involved must be made quickly, with little time for administrative or legal consultation. The psychiatrist's decision to participate in physically restraining or secluding a patient, particularly a child or adolescent, may have long-lasting consequences. This Open Forum is offered to promote a discussion on this topic. [ABSTRACT FROM AUTHOR]

Several factors have been shown to be involved in decisions to use seclusion and restraint in psychiatric inpatient settings. This study examined whether staff perceptions of factors related to the care team and violence on the ward predicted use of seclusion and restraint in psychiatric wards. Methods: A total of 309 staff members (nurses, rehabilitation instructors, and nurse's aides) providing care to patients with serious mental disorders were recruited from eight university psychiatric hospitals and general-hospital psychiatric units in the province of Quebec. Factors assessed included sociodemographic characteristics, psychological distress, staff perceptions of aggression and of interaction between members of the psychiatric team (team climate), and organizational factors. Results: Bivariate analyses showed that certain aspects of the team climate, staff perceptions of aggression, and organizational factors were associated with greater use of seclusion and restraint. The final multivariate model indicated that the following factors independently predicted greater use: type of hospital ward (emergency department and intensive care unit), staff perception of a higher level of expression of anger and aggression among team members, perception of the frequency of incidents of physical aggression against the self among patients, and perception of insufficient safety measures in the workplace. Conclusions: These findings represent the first stage of a research program aimed at reducing use of seclusion and restraint in psychiatric settings. They underscore the importance of evaluating a variety of factors, including perceptions of safety and violence, when examining reasons for use of these controversial interventions. [ABSTRACT FROM AUTHOR]

Use of restraint in acute psychiatric wards is highly controversial. Knowledge is limited about the characteristics of patients who are restrained and the predictors of use of restraint. This study examined whether restrained patients differed from nonrestrained patients in demographic, clinical, and medicolegal variables and to what extent the variables predicted use of restraint. Methods: A two-year retrospective case-control design was used. The sample comprised all restrained patients (N=375) and a randomly selected control group of nonrestrained patients (N=374) from three catchment-area-based acute psychiatric wards in Norway. Data sources were restraint protocols and electronic patient files. Results: The restrained patients were significantly younger and more likely to be men, to reside outside the wards' catchment areas, and to have an immigrant background. Restrained patients also had more admissions and longer inpatient stays than nonrestrained patients and were more likely to be involuntarily referred and to have one or more of the following ICD-10 diagnoses: a substance use disorder, schizophrenia or a related psychotic disorder, and bipolar disorder. Binary logistic regression analyses, adjusting for age, gender, immigrant background, and catchment area, indicated that the number of admissions, length of stay, legal basis for referral, and diagnosis each independently predicted the use of restraint. No interactions were found. Conclusions: Use of restraint was predicted by multiple admissions, long inpatient stays, involuntary admission, and serious mental illness. Identifying patients at risk may inform the development of alternatives to restraint for these patients. [ABSTRACT FROM AUTHOR]

Objective: This study examined usage patterns of restraint and seclusion before and after the implementation of collaborative problem solving (CPS), a manualized therapeutic program for working with aggressive children and adolescents. Methods: The clinical setting was a 15-bed psychiatric inpatient unit for school-age children. A total of 755 children were hospitalized for a total of 998 admissions from fiscal years 2003 to 2007 (median age= 11 years; 64% boys). Data were collected for three years before and 1.5 years after the six-month implementation of the CPS model of care. Results: There were 559 restraint and 1,671 seclusion events during the study period. After implementation of the CPS model there was a reduction in the use of restraints (from 263 events to seven events per year, representing a 37.6-fold reduction, slope [beta]=-.696) and seclusion (from 432 to 133 events per year, representing a 3.2-fold reduction, beta=-.423). The mean duration of restraints decreased from 41±8 to 18±20 minutes per episode, yielding cumulative unitwide restraint use that dropped from 16±10 to .3±.5 hours per month (a 45.5-fold reduction, beta=-.674). The mean duration of seclusion decreased from 27±5 to 21±5 minutes per episode, yielding cumulative unitwide seclusion use that dropped from 15±6 to 7±6 hours per month (a 2.2-fold reduction; p for trend .01 or better for all slopes). During the early phases of implementation there was a transient increase in staff injuries through patient assaults. Conclusions: CPS is a promising approach to reduce seclusion and restraint use in a child psychiatric inpatient setting. Future research and replication efforts are warranted to test its effectiveness in other restrictive settings. [ABSTRACT FROM AUTHOR]

Objective: This study investigated patterns of seclusion and restraint among patients hospitalized at a psychiatric facility with a large number of forensic psychiatric beds. Methods: Seclusion and restraint records were examined for 622 patients who were admitted during a five-year period (September 2001 to September 2006) and had a stay of at least 60 days. Seclusion and restraint episodes were recorded as bimonthly counts over the first two years after the initial admission. Latent class analysis was used to investigate the hypothesis that discrete seclusion and restraint trajectories exist. Results: Indices of model fit strongly supported the existence of three highly discrete trajectories. The low-trajectory class (71%) consisted of individuals who averaged less than .15 seclusion or restraint incidents per month over the course of their hospitalizations. Patients in the medium-trajectory class (22%) averaged approximately two incidents per month during the first two months, and rates declined to an average of about one incident per month by the end of the study period. Patients in the high-trajectory class (7%) averaged six incidents per month during the first two months, followed by a gradual decline in rates, where they then averaged two to three incidents per month by the end of the study period. The three groups differed significantly with respect to a number of diagnostic and demographic characteristics. While hospitalized, patients in the high-trajectory class were almost 30 times more likely to be named as perpetrators in incident and injury reports and 75 times more likely to be physically abused than patients in the low-trajectory class. Conclusions: These findings have implications for clinical and administrative decision makers with regard to assigning new admissions to appropriate security levels, targeting patients with specialized treatment interventions, and moving low-risk patients into less restrictive treatment environments. [ABSTRACT FROM AUTHOR]

Few analyses have been carried out in Japan concerning factors contributing to physical restraint of patients. We compared demographic data for 241 inpatients who were restrained during a 4-year period with data for 1093 inpatients who were not restrained in a general hospital psychiatric unit in Japan. Increased likelihood of restraint use was associated with older age, male gender, off-hours admission, involuntary hospitalization, transfer from other departments of the hospital, frequent hospitalization, absence of previous treatment, physical complications, history of suicide attempts, organic mental disorders, mental and behavioral disorders from psychoactive substance use, schizophrenia, schizotypal and delusional disorders. Importantly, physical complications not only were more prevalent among restrained than unrestrained patients, but additionally in restrained patients physical complications were associated with more prolonged hospitalization and periods under restraint than were associated with assaultive behavior or periods of unconsciousness. In conclusion, general hospital psychiatric units in Japan often treat patients with psychiatric disorders or symptoms that were associated with physical problems. Particular caution is needed in deciding whether such patients should be restrained since hospitalization may be prolonged or functional status compromised. [ABSTRACT FROM AUTHOR]

Examines the use of seclusion and mechanical restraint from the year 1990 to 2000 and the rate of staff injuries from patient assaults from the year 1998 to 2000 in Pennsylvania state hospital system. Calculation of the rate and duration of seclusion and restraint; Decrease of the average rate of seclusion; Assessment of the changes in the state hospital system.

Investigates the characteristics of adolescents who were restrained during brief inpatient psychiatric treatment in the United States. Relationship between restraint used and the characteristics of youths; Youth's history of voicing suicidal ideation and attempting suicide; Effectiveness of techniques to reduce aggression.

Locked inpatient units are an increasing phenomenon, introduced in response to unforseen abscondences and suicides of patients. This paper identifies some value issues concerning the practice of locked psychiatric inpatient units. Broad strategies, practicalities and ethical matters that must be considered in inpatient mental health services are also explored. The authors draw on the published research and commentary to derive relevant information to provide to patients and staff regarding the aims and rationales of locked units. Further debate is warranted in relation to best practice. Inpatient staff need to be aware of their practice values, be able to access education and supervision and negotiate apparent contradictions. Further patient/clinician focused enquiry is necessary to mitigate the negative and stigmatising effects of locked mental health units. [ABSTRACT FROM AUTHOR]

The article describes the use of portable pulse oximeter in identifying patients who have acute oxygen deficits, which can occur during physical or mechanical restraint. It cites the association between physical restraints of patients and asphyxiation. It explains the psychological benefits of using oximetry and stresses the need to incorporate pulse oximetry into restraint reduction programs.

Describes a program that aims to reduce the use of physical restraint on three psychiatric units of university hospital. Determination of stress triggers and personal crisis management strategies of patients through interview; Training of staff members in crisis de-escalation and nonviolent intervention; Decline in physical restraint rates after implementation of the program.

A group of 102 mechanically restrained hospital patients were studied to determine the safety of restraint use. All the patients were elderly, cognitively impaired, and had multiple chronic diseases. Twelve percent of patients developed new infections in the hospital and twenty-two percent developed new pressure sores (bedsores). Patients restrained for four days or more were more likely to develop pressure sores. Patients restrained for more than four days frequently contract diseases and should be closely monitored.

Previous studies have shown that there is considerable variation in the degree to which coercion is used in mental health institutions. This variation between institutions and even between wards is seen in many countries. Many factors have been put foreword to explain this variation in the use of coercion, but we still can't explain it. If we had a better understanding of these factors, we would know more about how the use of coercion can be reduced in mental health care. Measures of coercion in this study are amount of involuntary admissions, forced medications and use of restraints (bed-belts) on Norwegian acute-wards. Some of the factors explored in previous studies include geography, population size, patient characteristics, ward characteristics etc. Staff attitudes to the use of coercion are one factor that has not yet been investigated in this regard. The scope of this project is first to develop a questionnaire to measure staff attitudes to the use of coercion. The next step will be to investigate if differences in staff attitudes to coercion can explain some of the variation in the actual use of coercion on wards in the mental health service. The project will also deliver updated data-about how much coercion is used on Norwegian acute-wards in 2005/2006. This project is part of a big multi-center study on many aspects on Norwegian acute-wards (MAP). [ABSTRACT FROM AUTHOR]

Background Restraining patients prompts difficult dilemmas and conflicts for the caregivers. With the understanding that the nursing staff plays a significant role in the decision to restrain a patient, we examined the factors and reasons that influence the concept and positions of the nursing staff regarding patient restraint. We examined nurses' attitudes, environmental concerns and emotional response to physical restraint of psychiatric inpatients, using a questionnaire we constructed expressly for this study. Methods 111/130 (85.4%) nurses in a psychiatric hospital completed anonymous questionnaires regarding their attitudes towards using physical patient restraints. The findings were analyzed using chi square for dichotomous analysis, t-test, for consecutive analysis and ANOVA and MANCOVA analyses appropriate. Results Nurses reported that the main criteria for restraint were endangerment of the patient's self or surroundings. Bothersome actions and environmental conditions also significantly impacted nurses' decisions to physically restrain patients. Emotional reactions to restraining procedures as experienced by staff and perceived for patients was generally negative. Although the core guideline followed by the nursing staff, being that patient restraint is only appropriate when the patient is a danger to himself or to his surroundings is followed, an important minority of nurses considers restraint as practical means to reduce unruly behavior. The meaning and associations to restraint is influenced by a variety of factors, such as the environmental conditions during or preceding an event, the emotions of the staff, and how the staff perceives the patient's reactions. Conclusion Nurses should be trained to deal with violent patients, establish limits, and recognize the therapeutic aspect of restraints in order to respond assertively. [ABSTRACT FROM AUTHOR]

Objective To give an overview of the current knowledge on the epidemiology of in-patient violence and coercive measures in clinical psychiatry. Methods Many studies have been conducted on the epidemiology of in-patient violence by use of standardized scales such as the SOAS-R. Much research on patient and environment characteristics has been compromised by methodological flaws such as sample selection bias. Epidemiological data on the use of coercive measures is scarcely available in most countries, and different ways of reporting render comparisons difficult. Results Comparisons between countries indicate higher rates of in-patient violence in the Netherlands and in Sweden. The best predictors of in-patient violent behavior seem to be history of violent behavior, involuntary treatment, disturbed behaviors on the ward and severity of psychotic symptoms. To control such behavior, coercive measures of different types are widely used in apparently all countries. In Germany, full records of a set of hospitals are available for the recent years. 9% out of about 50,000 admissions were exposed to some kind of coercive measure. Figures from Switzerland and Finland show some differences in the patterns of frequency and duration of measures such as seclusion and mechanical restraint. Conclusion From the view of research, policy, public interest, and ethics, there is an urgent need to improve the data base particularly about the use of coercive measures in clinical psychiatry in many countries. [ABSTRACT FROM AUTHOR]

Background Patients who exhibit violent behavior or refuse medication during in-patient treatment are a challenge for clinical management. The management of those clinical situations is different in European countries with respect to legislation and clinical routine. Methods We selected three case vignettes which were considered as most typical and relevant by a vote among members of the European Violence in Psychiatry Research Group (EViPRG). Case 1 represents a voluntary in-patient who assaults a staff member, case 2 an involuntary patient who does not behave violently but refuses medication. In all three case vignettes the respective patients were presented as suffering from schizophrenia. From each of the participating 12 European countries, two experts were interviewed by a questionnaire about the typical clinical management and its legal requirements in these cases. Consensus among the country experts was reached after further discussion, if necessary. Results Considerable differences were found with respect to involvement of jurisdiction and police, application of involuntary medication, requirements for a transfer to forensic psychiatry, and use of coercive measures. Physical restraint, seclusion, and mechanical restraint each are common in some countries and forbidden or definitely not used in others. Conclusion More evidence from sound studies is required regarding safety, outcomes and ethical aspects of coercive treatment. [ABSTRACT FROM AUTHOR]

Background In 2004, two independent working groups in Germany and Switzerland compared the frequency and duration of coercive measures in standard psychiatric care across 14 psychiatric hospitals in Germany and Switzerland. The objective was to establish an international knowledge transfer process in order to reduce the frequency and duration of coercive measures on a long-term basis to an extent of necessity. Methods The incidence and duration of mechanical restraint and seclusion was reliably recorded across 7 Swiss and 7 German psychiatric hospitals during the one year period of 2004. Hospital structure characteristics and guidelines on coercive measures were analyzed. Results The results showed different patterns in the use of seclusion and restraint across Swiss and German hospitals. In the Swiss hospitals seclusion was more frequently used than restraint, whereas in German hospitals restraint was more frequently used than seclusion. The average duration of coercive measures was of significantly longer duration in Swiss than in German hospitals. The number of coercive measures per affected case was significantly higher in German than in Swiss hospitals. Associations of data on coercive measures with hospital structure characteristics and guidelines were significant. Conclusion International comparisons on coercive measures allow for knowledge transfer and critical reflection of national traditions in the use of coercive measures. The results clearly showed different patterns in the use of seclusion and mechanical restraint across Swiss and German hospitals. Hospital structure characteristics as well as the use of guidelines on coercive measures were associated with the frequency and duration of coercive measures, in German as well as in Swiss hospitals. [ABSTRACT FROM AUTHOR]

Background Patients with organic mental disorders (ICD 10 F0) are a high risk group in regard to being subject to coercive measures. Methods used in old age psychiatry tend to vary widely among European countries. Legal background, ethical considerations, staffing levels and techniques available in everyday practice are compared between two hospital settings in Germany and Wales. Implications of these on key outcome measures on the use of coercion in this patient group are discussed. Methods Coercive treatment was closely monitored in the German hospital setting. The recorded data on the use of restraints included length, duration, frequency and proportion of patients affected in each diagnostic group. In Wales similar data on the use of control and restraint techniques was documented for patients with a F0 diagnosis. Staffing levels were also compared for both settings. Results The methods of restraint used in both settings were very different, mostly due to legal implications and differences in ethical views. The proportions of patients subject to restraint were similar; however the length of the coercive measures seemed to depend on the method used. Holding techniques in Wales were associated with shorter duration compared to the use of mechanical restraint (belts) in Germany. In Wales twice as many nursing staff were available per occupied bed, which could also have influenced the use of restraint. In Germany, a reduction in the use of coercion over the years was noted, proving that staff training and attitude also play a crucial role. Conclusion Ethical and legal considerations, as well as available resources, have an impact on the use of coercive measures in patients with an organic mental health problem. Reflecting and monitoring local practice can lead to changes in staff's attitude and help to prevent the use of coercion. Even with high staffing levels, the use of coercion is still necessary in some cases to control aggression. [ABSTRACT FROM AUTHOR]

Background In response to national media attention on restraint and seclusion (R/S), state and national efforts in the USA have organized around the goal of eliminating their use. Several states/organizations have significantly reduced and stopped using these violent procedures. Participants will learn: 1) How some states/organizations changed treatment practice to prevent inpatient violence, 2) Why an understanding of trauma and factors contributing to treatment violence are essential, 3)Why the consumer and family voice is of key importance, 4) What state and national data indicates about the success of these efforts. Methods Massachusetts implemented a R/S prevention initiative after a process of data, literature, and better practice reviews. Leadership prioritized the effort and promoted education for staff. Ongoing training, strategic planning, and teaching helped to shift the ownership of the effort. Inpatient providers became equally responsible for the outcome. Effective culture change constructs/strategies were identified, helped to inform a federal initiative (SAMHSA/NASMHPD-NTAC), and were included in an emerging evidence-based curriculum of "Core Strategies" to prevent and reduce treatment violence and coercion. Results Massachusetts' child/adolescent hospitals decreased their use of mechanical restraint by 85% and medication restraint by 88%. Some programs stopped using R/S altogether. These changes induced hope and reduced costs. Conclusion The use of R/S can be prevented and reduced to a level where it occurs rarely. Effective strategies have been identified and are being implemented. Courageous, focused leadership, at all levels of each organization involved in this type of process, is key to the success of this culture change effort. [ABSTRACT FROM AUTHOR]

The Swedish Health and Medical Services Act states that health and medical care for all children, youth and adults shall: Be of a high standard and satisfy the patients need for security; Be easily accessible; Be based on respect for the patients right to self-determination and integrity; Promote good communication between the patient and health and medical care personnel. The use of restraint and seclusion in psychiatric care is regulated by the same law on compulsory psychiatric care (the current version was passed in 1991) for all ages. It states that coercive measures should be used only when there were no other alternatives. A court decision is needed and compulsory care includes: Compulsory medication; To be held with force; Isolation; Ban of visitors; Forbidden objects can be taken into custody. A caring attitude at wards based upon the UN Declaration of the Rights of the Child together with the paragraphs from above on "on respect for the patients right to self-determination and integrity" and to "promote good communication between the patient and health and medical care personnel" including the child and his/her parents/legal guardians has minimized the use of restraint and seclusion in child and adolescent psychiatric care. "Quiet rooms" do not exist and the needs to use compulsory medication and to hold children with force have been rare occasions. To create a caring attitude of this kind is essentially depending on how the staff is selected and on their awareness and education. [ABSTRACT FROM AUTHOR]

Background The practice of physical restraint in psychiatric emergency practice is rather frequent. Patients with substance abuse more often present aggressive behavior requiring physical restraint in such settings. The legal frame for such practice in our country is defined in the Law for the protection of persons with mental disturbances. Patients admitted to a psychiatric emergency ward were analyzed prospectively according to their need of physical restraint. Methods We present results of a six month prospective study (September 2006 - March 2007) in which the role of substance abuse will be considered in relation to physical restraint during the stay in an emergency ward. Specific circumstances at admission, demographic data such as age, sex, and years of education will be obtained. Clinical data like diagnosis and specific substance abuse will also be analyzed. [ABSTRACT FROM AUTHOR]

Background In our psychiatric hospital we have a guideline in order to regulate the use of coercitive measures (isolation in specials rooms and use of safety straps). These measures are the last kind of intervention we use. The guideline defines us the procedure for using the different measures, nursing and medical cares, controls, observation, etc. In this work we analyze the use of coercive measures in our psychiatric unit. Methods When verbal coercion is not enough, sometimes it is necessary to use coercive measures to avoid injuries to the patient himself or to other patients. From June 2006 to December 2006, we collected the reasons to enter in an isolation-rooms unit (a special sub-unit with 10 rooms, one dining room, washrooms, medical office, sickbay, one patio) and when it was necessary to use mechanical restraint. Results The sample comprised 206 patients, approximately staying for 3 months. 53.9% were male, and 46.1% were female. Average age was 40.3 years (19-77). The most frequent diagnoses were schizophrenia (58.7%), affective psychoses (9.7%), other psychoses (12.1%), use of toxic substances (6.8%), personality disorders (4.8%), and other diagnoses (7.8%). During the 6 month study period the use of the isolated-rooms unit occurred in 1,139 times (56.1%) because of a behavioral disorder, 862 times (42.5%) because of a worsening of psychotic symptoms, and in 28 times (1.4%) because of drug abuse. It was necessary to use mechanical restraint in 89 times. Conclusion The number of coercive measures are used often enough to became a management indicator in order to improve our clinical practice like attitudes of professionals, safety measures, ethical aspects or alternatives to the coercive treatment. When verbal coercion is not enough, the most frequently used coercive measure was isolation. Mechanical restraint was used only in 4% of all incidents. The most frequent reason to use the isolated-rooms unit was behavioral disorders. [ABSTRACT FROM AUTHOR]

Background Previous studies show inconsistent findings about gender association with seclusion and restraint. A study from an acute emergency department showed that the number of women secluded and restrained were lower than for the men. But among repeatedly secluded and restrained patients the women were in the majority and they also had more episodes with seclusion and restraint. Methods In an ongoing multi-center study conducted in three acute emergency psychiatry institutions, we retrospectively examine data from seclusion and restraint protocols and data about all the patients admitted over a two-year period. We note how many patients have had episodes with seclusion and restraint. We also note duration/time/ date of each episode and the reason given for using seclusion and restraint and the relationship by gender. Each patient is only counted once in this period, controlling for readmission. Results Preliminary findings from one of the departments replicate findings in the study from the 1994 - 1999, that the total number of men secluded and restrained was higher than that of women, but among repeatedly secluded and restrained patients the women were in the majority. At the congress we will present results from all three departments. Conclusion Our data indicate that the use of seclusion and restraints varies by gender and show the need to study not only the rate of seclusion and restraint, but also the episodes of seclusion and restraint by gender. [ABSTRACT FROM AUTHOR]

Background Restraint of psychiatric patients is an ethical issue, emphasized by awareness of the rights of mentally ill individuals. Restraint significantly influences the emotional welfare of the patient, is traumatic, deprives the individual of freedom and has aggressive connotations. Aims: To examine the influence of raising the awareness of the staff to reduce use of physical restraints. Hypothesis: Raising the awareness of the staff will lead to a reduction in the number of restraining orders, the duration of restraints and the number of patients restrained. Methods We collected data regarding the number of restraints. Intervention included reduction of restraint policy and tri-monthly meetings to evaluate use of restraints and alternative methods which avoid physical restraints. Data were collected anonymously from four departments where physical restraints are used. Data collection took place twice: following the year of awareness intervention (July 2005 - June 2006), and was compared to the previous year (July 2004 - June 2005), when there was no intervention. Results Significant correlations were found between the groups before and after the intervention. The mean number of restraint orders prior to the intervention was 30.8 (SD = 24.4) and after intervention 22.4 (SD = 1 7.6); p = .03, t = 2.3. There was no significant difference between the departments in the reduction of restraint orders. In the year prior to intervention there was no correlation between occupancy and the number of restraints, and one year post intervention there was a significant correlation between occupancy and the number of restraint orders (p = .001) and occupancy and the number of patients restrained (p = .001). Conclusion Intervention to raise the awareness of the staff to reduce restraints was effective and lead to a reduction in the number of restraints. This is important for creating a professional, supportive, and safe therapeutic environment for the patients. [ABSTRACT FROM AUTHOR]

Background Coercive measures are associated with high strain for staff members. Most commonly used are mechanical restraint and seclusion. Both interventions are relatively secure and are considered as helpful in prevention of serious harm to self or others when other means are ineffective. Methods Interviews with staff members were conducted focusing on a coercive measure they had carried out shortly before. The half-structured interview questioned how severely the patient's human rights were restricted during the coercive measure. We measured the restriction of human rights by a scale developed for this purpose, Human DIgnity during COercive Procedures, DICOP. It consists of the aspects human dignity, ability to move, autonomy, coercion applied at the beginning of the measure, and restriction of contact. In addition staff members estimated the restriction of human rights by seclusion and mechanical restraint in general. Interviews of 39 staff members referring to 94 coercive measures were obtained. Results In general seclusion is estimated as the measure with lower impact on the restrictions of human rights and is largely preferred by staff members. In the assessments of concrete coercive measures which had been carried out shortly before mechanical restraint was rated as the much more restricting measure concerning human rights. Though staff members preferred seclusion in general, they considered the measure carried out shortly before as the adequate one even if it was mechanical restraint. Conclusion From the staff members' point of view seclusion seems to be less restrictive, but there are obviously attitudes to prefer mechanical restraint in specific situations. Indications for mechanical restraint might be severe psychomotoric agitation, requirement of monitoring continuously or in short intervals, and preference expressed by the patient. Further research should focus on differential indications between different kinds of coercive measures. [ABSTRACT FROM AUTHOR]

Background Seclusion and mechanical restraint are widely used for people with serious mental disorders. In most countries one intervention is preferred while the other is considered as inhuman or not sufficiently safe, but identical arguments refer to different preferences. There is a lack of evidence from well-designed studies on compulsory measures in psychiatry. Methods We conducted a cohort study with optional randomisation comparing seclusion and mechanical restraint among in-patients with acute psychotic disorders. We determined an ethical aspect as main outcome variable: the restriction of human rights from the patients' point of view, measured by a scale developed for this purpose, Human DIgnity during COercive Procedures, DICOP. In addition we screened for posttraumatic stress disorder (PTSD). After one year a follow-up was conducted by telephone interviews. We reassessed the incidence of PTSD after coercive measures by the Impact of Event Scale (IES). Results 102 out of 233 patients exposed to coercive measures within 24 months could be included, 26 could be randomized (12 seclusion, 14 restraint). 60 patients could be contacted for follow-up interviews. Further results will be presented. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to previous letters on the feasibility of eliminating the use of restraint and seclusion in psychiatry in the April and July 2006 issues.