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This article analyses the use of coercive measures in two national institutions for high-security psychiatry in Norway – Kriminalasylet (Criminal Asylum) and Reitgjerdet – during the period 1895–1978. Historical study of coercion in psychiatry is a fruitful approach to new insight into the moral and ethical considerations within the institutions. We approach the topic through a qualitative study of patient case files and ward reports from the institutions' archives, as well as a comprehensive quantification of the coercive measures used. The data show shifting considerations of humane treatment and changes in the respect for human dignity in the institutions' practices. They also show that technological developments, such as the introduction of new psychopharmaceuticals, did not necessarily lead to higher standards of treatment. [ABSTRACT FROM AUTHOR]

When other options fail, physical restraint is used in inpatient psychiatric units as a means to control violent behavior of agitated inpatients and to prevent them from harm. The professional and social discourse regarding the use of restrictive measures and the absence of the inpatients’ attitudes towards these measures is notable. Our research therefore tries to fill this gap by interviewing inpatients about these issues. To assess the subjective experience and attitudes of inpatients who have undergone physical restraint. Forty inpatients diagnosed with psychiatric disorders were interviewed by way of a structured questionnaire. Descriptive statistics were conducted via use of SPSS statistical software. 1.Inpatients reported that physical restraint evoked an experience of loneliness (77.5%) and loss of autonomy (82.5%). 2.Staff visits during times of physical restraint were reported as beneficial according to 73.6% of the inpatients interviewed. 3.Two thirds of the inpatients viewed the use of physical restraints as justified when an inpatient was dangerous. 4.Two thirds of the inpatients regarded physical restraint as the most aversive experience of their hospitalization. Our pilot study explored the subjective experience and attitudes of psychiatric inpatients towards the use of physical restraint. Inpatients viewed physical restraint as a practice that was sometimes justified but at the same time evoked negative subjective feelings. We conclude that listening to inpatients’ perspectives can help caregivers to evaluate these measures. [ABSTRACT FROM AUTHOR]

Abstract: In Western society, policy and legislation seeks to minimize restrictive interventions, including physical restraint; yet research suggests the use of such practices continues to raise concerns. Whilst international agreement has sought to define physical restraint, diversity in the way in which countries use restraint remains disparate. Research to date has reported on statistics regarding restraint, how and why it is used, and staff and service user perspectives about its use. However, there is limited evidence directly exploring the physical and psychological harm restraint may cause to people being cared for within mental health inpatient settings. This study reports on an integrative review of the literature exploring available evidence regarding the physical and psychological impact of restraint. The review included both experimental and nonexperimental research papers, using Cooper's (1998) five‐stage approach to synthesize the findings. Eight themes emerged: Trauma/retraumatization; Distress; Fear; Feeling ignored; Control; Power; Calm; and Dehumanizing conditions. In conclusion, whilst further research is required regarding the physical and psychological implications of physical restraint in mental health settings, mental health nurses are in a prime position to use their skills and knowledge to address the issues identified to eradicate the use of restraint and better meet the needs of those experiencing mental illness. [ABSTRACT FROM AUTHOR]

Coercive measures like mechanical restraint (MR) are widely used in psychiatry but may collide with bioethical autonomy principles, damage those involved, and harm patient–staff relations. Reductions in usage are desirable and addressing illegitimate MR would be an obvious starting point. As one important reason for instigating MR is dangerous patient behavior this attracts special attention. In this complaints audit the role of threats, violence, and contextual characteristics was examined in decisions concerning MR completed by the Danish Psychiatric Patient Complaint Board system from 2007 to 2014. According to case descriptions, threats and violence were common and sometimes rather serious. Mainly actualized physical violence seemed to justify MR use. However, roughly every sixth patient subject to MR episodes filed a complaint and in one in 25, usage was found unlawful. The interpretation of clinical situations vs. law elements and surrounding coercion legislation needs further investigation as does the impact of, e.g. psychiatry staffing. [ABSTRACT FROM PUBLISHER]

The use of seclusion and restraints (SR) in acute hospital settings remains a controversial practice. Despite the focus on SR in the psychiatric services literature, data on SR use in pediatric day hospital settings is lacking. A case-control retrospective analysis for children admitted into a pediatric psychiatry day hospital in a 2-year span examined predictors of SR use. Demographic and clinical descriptors were examined in relation to SR events using univariate and multivariate regression models. Significant univariate risk factors for SR use were psychiatric morbidity, history of physical abuse, post-traumatic stress disorder, having any anxiety disorder, and younger age. Knowledge of risk factors for SR use in pediatric psychiatric day hospitals can avert use of SR and lead to improved safety in a trauma-informed care model. [ABSTRACT FROM AUTHOR]

Restraint use in psychiatry has been a topic of clinical and ethical debate for years. As much as the medical community desires to attain the goal of a restraint-free environment, there are not many alternatives available when it comes to protecting the safety of violent patients and those around them. Our objective was to examine patterns of restraint use and analyze the factors leading to its use in adult psychiatric inpatient units. We conducted a retrospective review of restraint orders from January 2007 to December 2012, for inpatient units at a community mental health hospital, examining-unit, patient gender, number and duration of restraint episodes, time of day, and whether medications and/or verbal redirection were used. For the 6-year period studied, a total of 1753 restraint order-sheets were filed for 455 patients. Mixed-model regression found significant differences in duration of restraint episodes depending on: patient gender, unit, medication use, verbal redirection and AM/PM shifts. These differences were consistent over time with no significant interactions with years and remained significant when included together in an overall multivariate model. We elucidate variable patterns of restraint utilization correlating with elements such as patient gender, time of day and staff shift, medication use, and attempts at verbally redirecting the patient. Besides providing much needed data on the intricate dynamics influencing restraint use, we suggest steps to implement hospital-wide restraint-reduction initiatives including cultural changes related to restraint usage, enhanced staff-training in conflict de-escalation techniques and personalized treatment plans for foreseeable restraint episodes. [ABSTRACT FROM AUTHOR]

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]

This article uses narrative analysis to understand how mental health professionals working in a pilot experiment in community psychiatry in France between 1960 and 1980 made sense of their work experiences. Based on a collection of essays written by these professionals as part of their training as well as on other archival materials, the article explores writing practices in post-war French psychiatry as ways of constructing and negotiating moral commitments to work. The first three sections of the article give some background on mental health nursing in France in the immediate post-war period. The subsequent three sections examine how the professionals elaborated on their experiences in their writings, focusing on three different levels: first, the narrative voice used in the essays; second, the learning processes described by trainees; and finally, the ways in which they negotiated discursively the requirement to do emotionally well at work. [ABSTRACT FROM AUTHOR]

This article investigates the ambivalence of front-line mental health clinicians toward their power to impose treatment against people's will. Ambivalence denotes both inward uncertainty and a collective process that emerges in the midst of everyday work. In their commentaries about ambivalence, providers struggle with the distance separating their preferred professional self-image as caring from the routine practices of constraint. A detailed case study, drawn from 2 years of qualitative research in a U.S. community psychiatry agency, traces providers' response to the major tools of constraint common in such settings: outpatient commitment and collusion between the mental health and criminal justice systems. The case features a near-breakdown of clinical work caused by sharp disagreements over the ethical legitimacy of constraint. The ethnography depicts clinicians' experience of ambivalence as the complex product of their professional socialization, their relationships with clients, and on-going workplace debates about allowable and forbidden uses of power. As people articulate their ethical sensibility toward constraint, they stumble over the enduring fault lines of community psychiatry, and they also develop an ethos of care tailored to the immediate circumstances, the implicit ideologies, and the broad social contexts of their work. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to investigate restraint use in Australian emergency departments (EDs).Method: A retrospective audit of restraint incidents in four EDs (from 1 January 2010 to 31 December 2011).Results: The restraint rate was 0.04% of total ED presentations. Males and females were involved in similar numbers of incidents. Over 90% of restrained patients had a mental illness diagnosis and were compulsorily hospitalised. Mechanical restraint with the use of soft shackles was the main method used. Restraint was enacted to prevent harm to self and/or others. Median incident duration was 2 hours 5 minutes.Conclusions: In order to better integrate the needs of mental health clients, consideration is needed as to what improvements to procedures and the ED environment can be made. EDs should particularly focus on reducing restraint duration and the use of hard shackles. [ABSTRACT FROM AUTHOR]

Objectives: Restrictive interventions (seclusion, physical restraint, and use of acute/p.r.n. sedation) may have negative effects on patients. Identifying factors associated with use of restrictive interventions and examining their effect on admission outcomes is important for optimising inpatient psychiatric care.Methods: This study documented use of restrictive interventions within a child and adolescent psychiatric inpatient unit for 15 months. Two models examined predictors of use of restrictive interventions: (i) incident characteristics; and (ii) patient characteristics. The relationship between use of restrictive interventions and global clinical outcomes was also examined.Results: Of 134 patients admitted during the study period (61.9% female, mean age=13.8±2.9 years), 26.9% received at least one restrictive intervention. Incident factors associated with restrictive interventions were: physical aggression, early admission stage, and occurrence in private space. Patient factors that predicted use of restrictive interventions were developmental disorder and younger age. Use of restrictive interventions was not associated with increased length of stay or diminished improvement in global symptom ratings.Conclusions: Further research is needed to identify best practice in children at high risk for receiving restrictive interventions. [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]

Purpose: Previous research has shown considerable differences in how often coercive measures are used in mental health care between groups of patients, institutions and geographical areas. Staff attitudes towards the use of coercion have been put forward as a factor that may influence these differences. Method: This study investigates the attitudes to coercion in 651 staff members within 33 Norwegian acute psychiatric wards. The newly developed Staff Attitude to Coercion Scale was used to measure staff attitudes. Results: Multilevel analysis showed that there was significant variance among wards, estimated to be about 8-11% of the total variance on three scales. Conclusions: Despite substantial differences in attitudes among wards, most of the variance could be attributed to individual staff level factors. Hence, it is likely that staff attitudes are influenced, to a large extent, by each individual staff member's personality and values. [ABSTRACT FROM AUTHOR]

The aim of this study was to report on forensic rehabilitation inpatients' experiences and preferences for physical restraint, seclusion and emergency intra-muscular medication using mixed qualitative and quantitative methods. Of 252 inpatients, 79 met the study inclusion criteria and 57 (72%) agreed to take part. Just over half thought they should have been subjected to coercive treatment. Although coercive treatments were generally perceived as negative experiences, 16% of participants reported the last episode of seclusion or restraint had been a positive experience for them. The figure for emergency intra-muscular medication was 36%. Eleven percent of participants said they had made an advance statement but none could be found in their records. Most participants preferred intra-muscular medication to seclusion. Participants made suggestions as to how to improve their experiences of coercive treatments. Patients' views on coercive treatments should be incorporated into their care plans and they should be encouraged to make advance statements. [ABSTRACT FROM AUTHOR]

The article discusses the Deprivation of Liberty Safeguards (DOLS) introduced into the Mental Capacity Act (MCA) via a closure of the "Bournewood Gap" legislative loophole. Mentally disabled patients who lack capacity but who comply with admission and treatment reportedly fall into this gap and the measure ensures their liberty deprivation accords with law. Cast in this light, it is stated that the grounds for distinguishing between liberty deprivation and activity restriction of a patient to ensure his or her well-being have to be determined.

The article discusses the basic compatibility of the presumed capacity principle implicit within the Mental Capacity Act (MCA) and the likely routine capacity assessment under the Deprivation of Liberty Safeguards (DOLS). The concerns for conflict are reportedly in the incompatibility between the occasionalist approach in the MCA and the possible authorizations in the DOLS. It is stated that the assessment of capacity only to make particular decisions when needed conflicts with DOLS because this will allow deprivation of liberty for extended periods.

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]

The article focuses on the improvements in mental health law in the U.S. It states that the Mental Health Law Reform Commission of the Commonwealth of Virginia has introduced two legislative proposals such as the temporary detention order (TDO) for back-up facility and the substitute consent to treatment for its 2012 General Assembly Session. It mentions that the Inspector General for Behavioral Health and Developmental Services (IG) has released the results on the use of restraints to abuse and neglect upon the advice of the Office of the Virginia Attorney General (OAG). It adds that the Ninth Circuit Court of Appeals reversed the decision of the Idaho federal district court, which granted a new sentence hearing to a defendant sentenced to death for ineffective assistance of counsel.

This review examines the nature and effectiveness of interventions to reduce the use of mechanical restraint and seclusion among adult psychiatric inpatients. Thirty-six post-1960 empirical studies were identified. The interventions were diverse, but commonly included new restraint or seclusion policies, staffing changes, staff training, case review procedures, or crisis management initiatives. Most studies reported reduced levels of mechanical restraint and/or seclusion, but the standard of evidence was poor. The research did not address which programme components were most successful. More attention should be paid to understanding how interventions work, particularly from the perspective of nursing staff, an issue that is largely overlooked. [ABSTRACT FROM AUTHOR]

Background: The containment or the prevention of actual violence is the primary justification for the use of restraint and seclusion in psychiatry. The aim of the present study was to determine the grounds for using restraint and seclusion in clinical practice in Finland, and whether these reasons have changed over a 15-year period as a result of legislative changes. Method: A structured postal survey concerning the reasons for restraint and seclusion was completed in all the Finnish psychiatric hospitals during a predetermined week in 1990, 1991, 1994, 1998 and 2004. The duration of the episode as well as demographic and clinical information on the restrained and secluded patient were also reported. Results: Agitation/disorientation was the most frequent reason for the use of restraint and seclusion. The duration of the restraint and seclusion episodes was not determined by the reason for using these measures. Some differences in the reasons were found among subgroups of patients. Conclusion: Clinical practice deviates from the theoretical and legal grounds established for restraint and seclusion, and is too open to subjective assessment and interpretations. [ABSTRACT FROM AUTHOR]

Physical restraints are used as a psychiatric intervention to protect psychiatric inpatients from self-harm or harm to others, by securing a safe environment for the patients and staff. We examined nurses' attitudes, environmental concerns, and emotional responses to physical restraint of psychiatric inpatients, using a questionnaire we constructed expressly for this study. 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 as perceived for patients were generally negative. 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]

Use of physical restraint in acute care psychiatry has been, and continues to be, a controversial issue. For this reason, a study was conducted in 1996 that examined nurses' decision making related to the use of physical restraint with aggressive psychiatric patients. An instrument, the Moylan Assessment of Progressive Aggression Tool (MAPAT), was developed for this purpose. Information relating to this instrument has not been previously published. It is currently in use in an ongoing research study by the author. A description of the process of the development of the MAPAT is provided here, along with the validity and reliability of the instrument, and implications for potential use in research, training, and education. [ABSTRACT FROM AUTHOR]

The term control and restraint (C&R) has been in common use in mental health practice for the past 20 years. This article explores the appropriateness of its continued use, drawing briefly on frame theory -- a subtype of discourse analysis. The authors conclude that, apart from a brief period in the 1980s, when the prison service oversaw training in physical interventions in the NHS, there has been confusion over the meaning of the term. Its continued use reflects an attribution whereby the primary source of violence is seen as 'within' the patient, instead of being seen as 'co-created', a more appropriate view in light of the public health model of violence prevention. However, any change in language must be accompanied by a shift in thinking and practice. The article puts forward a rationale for stopping the use of the term and calls for a radical change and the adoption of restraint reduction as a policy objective. [ABSTRACT FROM AUTHOR]

Accessible summary · Information about the use of manual restraint to manage violent or challenging behaviour in psychiatric hospitals is relatively scarce. This review includes 45 studies of manual restraint of adult psychiatric inpatients, mostly from the UK. · Overall, the research suggests that manual restraint is used up to five times per month on an average ward, lasts for about 10 min and tends to involve patients being restrained face down on the floor. Manually restrained patients are young, male and detained under mental health legislation. · We conclude that more and better-quality research is needed to improve knowledge of how manual restraint is used in response to different types of incident and in different types of ward/hospital. Relatively little is known about the prevalence of manual restraint to manage violent or challenging behaviour in hospital psychiatric services or the circumstances of its use. This review identified 45 empirical studies of manual restraint of adult psychiatric inpatients, mostly from the UK. On average, up to five episodes per month of manual restraint might be expected on an average 20-bed ward. Episodes last around 10 min, with about half involving the restraint of patients on the floor, usually in the prone position. Manually restrained patients tend to be younger, male and detained under mental health legislation. Staff value restraint-related training, but its impact on nursing practice has not been evaluated. Research has tended to focus on official reports of violent incidents rather than manual restraint per se. Larger and more complex studies are needed to examine how manual restraint is used in response to different types of incident and in different service settings. [ABSTRACT FROM AUTHOR]

Abstract: Psychiatric Intensive Care Units (PICU) propose a secure setting for patients with acute behavior disturbances who can not be managed in psychiatric general wards. Physical violence acts against patients or hospital staff, substance abuse, non-compliance for care and treatment, intensity of symptoms or absconding are frequent motives for admission. Patients are compulsorily detained in secure conditions. They are admitted from psychiatric facilities of a health area or by agreement between hospitals. Multidisciplinary working in psychiatric intensive care is essential, delivered by qualified staff. Care and treatment must be centered on the patient, multidisciplinary, intensive, comprehensive with an immediacy of response to critical situations. As length of stay should not exceed 2 months in duration, interface and liaison with original services of patients are important issues. In France, PICU exist notably at Cadillac, Lyon, Paris, Nice, Eygurande, Montpellier, Pau and Prémontré. These facilities appear as a missing level, an interesting alternative in mental health care system, between psychiatric general wards and maximum security hospitals. This paper reports the creation of a National Association of PICU in France, the existence of national minimum standards and international experiences. [Copyright &y& Elsevier]

This article explores the photographic physiognomy of Victorian asylum super-intendent Hugh Welch Diamond. Through close readings of Diamond's photographs as well as commentary published by Diamond and Dr John Conolly, the author argues that Diamond expanded the meaning of the word physiognomy to include metonymic traits such as clothing and hairstyle. Diamond used physiognomy for both diagnostic and therapeutic purposes, and he staged his photographs to maximize their efficacy for both, creating a mediated mirror through which his patients viewed themselves. Through photographic physiognomy, Diamond tried to change the nature of asylum practice, using images of his patients to nurture them to health without physical restraints. [ABSTRACT FROM AUTHOR]

PURPOSE. This study aimed to explore nurses' ( N= 22) and physicians' ( N= 5) educational needs in the context of their perceived seclusion and restraint-related mode of action and need for support. METHOD. The data were collected by focus group ( N= 4) interviews and analyzed with inductive content analysis. RESULTS. Participants recognized a need for on-ward and problem-based education and infrastructural and managerial support. The declared high ethical principles were not in accordance with the participants' reliance on manpower and the high seclusion and restraint rates. PRACTICE IMPLICATIONS. Future educational programs should bring together written clinical guidelines, education on ethical and legal issues, and the staff's support aspect. [ABSTRACT FROM AUTHOR]

Seclusion with or without restraint is a measure for managing aggressive or agitated clients and promoting site security, particularly in an emergency psychiatric setting. The decision to control a potentially dangerous person's behaviour by removal or seclusion seems ethically justifiable in such a setting. However, although the decisions on these restrictive measures are based on rational needs, they are also influenced by the healthcare team's perceptions of the client and by the characteristics of the team and the environment. The purpose of this paper is to set out and categorize the factors in play in aggression- and agitationmanagement situations as perceived by the healthcare teams, particularly the nurses. The first part of the paper deals briefly with the settings in which control measures are applied in a province in eastern Canada and the effect of such measures on patients and healthcare teams. The second part identifies the factors involved in the management of agitation and aggression behaviour. The final part discusses the current spin-offs from this knowledge as well as promising paths for further research on the factors involved. The ultimate objective is to reduce recourse to coercive measures and enhance professional practices. [ABSTRACT FROM AUTHOR]

Physical intervention training courses are commonplace events in psychiatric and mental healthcare settings across the UK. While there is still debate as to what techniques should be taught on such courses, there is good evidence as to the mechanisms whereby pain, injury and even death can be inflicted. There is also a wealth of literature identifying how organizational culture can influence the quality of service delivery and standards of client care. It is well documented that the dignity, well-being and physical integrity of service users can be compromised by staff acts and omissions stemming from corrupted cultures. What has not been explored in detail to date is the role of physical intervention trainer, specifically the values they model and how these may influence the readiness with which staff resort to physical restraint strategies. It is possible that even approved physical techniques can become compromised through poor training technique and expose end recipients to needless humiliation and potential harm. This paper discusses this area of practice, offers insight on how the learning process is compromised by trainers and suggests areas for future research. [ABSTRACT FROM AUTHOR]

Background There is little research on the safety of the various types of restraint commonly used with individuals with intellectual disabilities who exhibit severely aggressive or self-injurious behaviour. Method This study analysed the use of restraint with 209 individuals with intellectual disabilities over a 12-month period. Results Planned restraint, the use of restraint as a component of a behaviour treatment programme (i.e. planned personal or planned mechanical restraint) was safer than crisis-intervention restraint (emergency personal or emergency mechanical). The overall rate of injuries during restraint was 0.46 injuries per hundred restraints. Restraint was applied 99.54% of the time without injury. Conclusion Restraint was relatively safe and safer than reported in one other study. Planned restraint was safer than emergency restraint. The additional training and programme development associated with planned restraint may have contributed to the greater safety of planned restraint. Due to limited empirical data, restraint safety has yet to be established and this study suggests that restraint should be decreased and closely monitored. [ABSTRACT FROM AUTHOR]

Background Previous evidence has suggested that clinical characteristics may predict use of restraint in adults with intellectual disability. However, the relationship between specific types of untoward incidents, corresponding interventions (restrictive procedures) and clinical psychopathology remains unclear. Method We examined all untoward incidents ( n = 397) that were recorded for a group of service users ( n = 65) referred to a specialist unit for adults with intellectual disability over a 6-year period. Associations between different restrictive procedures and clinical psychopathology were investigated. Results Physical assault was the most common incident associated with physical restraint, male gender and presence of autism. De-escalation was the most frequently employed intervention associated with less serious incidents such as verbal abuse and theft. Conclusions Specific interventions seem to be associated with different types of incidents and presence of autism. The results are discussed in terms of clinical practice and possible future directions. [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]

The article presents a study which measures the efficacy of installing a padded seclusion room to decrease the use of mechanical restraints in psychiatric intervention. The findings indicate that the use of a padded seclusion room on a state adolescent female psychiatric inpatient unit significantly reduced the rate of mechanical restraint by 93.9%, and its use did not increase the time patients spent in seclusion nor did it increase the summed number of seclusion events plus restraint events.

To ascertain the presence, and describe the pattern and extent, of restrictive care practices in the treatment of mental health inpatients in a rural New Zealand unit. Retrospective data was anonymously extracted from patient records at Rotorua Hospital (Rotorua, New Zealand). Data sets were compiled from 300 consecutive patient admissions between January 2000 and December 2001. The demographic and diagnostic characteristics extracted were gender, age, ethnicity (Māori or non-Māori classification only), primary diagnosis, length of hospital stay, seclusion, medication on discharge, dosage of antipsychotic medication if given, referral to psychotherapy, voluntary/involuntary status on admission, and readmission rates. After controlling for other clinical variables, ethnicity was not associated with specific diagnoses, increased use of seclusion, and involuntary status on admission or higher readmission rates. Māori patients were more likely to receive antipsychotic medication and at higher doses than non-Māori. Māori were less likely to be referred to psychotherapy services and had shorter lengths of stay. There was no evidence of widespread restrictive care practices against Māori, although the disparities in antipsychotic prescription and psychotherapy referral suggest some restrictive care practices do exist. The use of specialist cultural teams in general mental health services may prevent restrictive care practices. [ABSTRACT FROM AUTHOR]

The goal of this study was to examine the utility of clinical records of psychiatrically hospitalized youth for predicting critical incidents during treatment. Intake data from inpatients (N = 484, mean age = 14 years) in a secure psychiatric facility were coded for the presence of theoretically based individual and contextual risk factor information and analyzed prospectively to predict youths' involvement in incidents of seclusion and restraint. Findings indicated that whereas several individual and contextual risk factors accounted for the likelihood of a youth becoming involved in seclusion or restraint, only histories of various types of aggression, number of prior residential placements and body mass index could predict the extent of this involvement. The implications of these findings with respect to ecologically valid research and empirically informed practice with high-risk youth are discussed. [ABSTRACT FROM AUTHOR]

The use of seclusion or restraint (S/R) as an emergency medical intervention to assist patients in regaining behavioral control continues to be an area of interest and concern for the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), consistent with the ongoing concerns in the medical, patient advocate, legislative and legal communities. This study examined unit characteristics and the use of S/R in a VA facility with a secured, acute mental health unit before and after the promulgation of the JCAHO 2000 standards for utilization of S/R for behavioral health reasons. Variables examined include patient acuity, patient census, number of admits, number of discharges, length of stay, number of nursing staff on duty, critical incidents and S/R hours per month. Results indicated S/R use began showing a notable decrease corresponding to the time that senior unit management began discussions of the new JCAHO standards. These reductions maintained statistical significance even after controlling for changes in unit environmental variables. [ABSTRACT FROM AUTHOR]

This article describes the use of rapid response teams to reduce the use of mechanical restraints (i.e., restricting a person's movement through the use of a mechanical device such as a backboard, net, or papoose) in an acute psychiatric care setting. Rapid response teams have proven highly effective for emergent medical patients, but have not typically been used in behavioral health care settings. Utilizing a rapid cycle process improvement approach, a response team was convened following each episode of mechanical restraint in an inpatient psychiatric treatment facility. Initial results, during a 6-week rapid cycle change process, showed that mechanical restraints were reduced by 36.4% when compared with a 6-week baseline and when compared with a 1-year baseline. Changes in hospital census during the implementation process did not appear to account for the reduction in restraints. Rapid response teams and rapid cycle process improvement are discussed as useful change vehicles for behavioral health care organizations. [ABSTRACT FROM AUTHOR]

Manual restraint techniques are associated with the management of violence in psychiatric settings. Restraint effectiveness and acceptability are under scrutiny, yet the nature and frequency of who or what were involved in restraint episodes have not previously been fully described or understood. The aim of this study was to describe the nature and frequency of manual restraint-related events and their components. This study was carried out using content analyses of nurses’ post-incident reports from a psychiatric unit situated within a general hospital, and from its associated medium-secure unit. Requests for restraint occurred at the rate of about once per day, and the majority related to patients’ ill-directed frustration, resistance to containment and their desire to leave the ward. Only half of responses to conflicts resulted in restraint implementation. The majority of restraint activities occurred during the afternoon and night. Male patients and detained patients were more frequent participants in restraint interventions. To a lesser extent, police, ambulance, fire services, hospital security, visitors and ex-patients were also involved in restraint episodes. Injuries were rare. In conclusion, training in restraint skills, clinical audit of adverse incidents, and research into psychiatric aggression all need to take into account the association of restraint with the enforcement of detention and treatment of acutely ill patients. The coupling of restraint with medication requires examination of its safety and efficacy. Interagency training may enable the essential services involved to coordinate restraint activities more effectively. [ABSTRACT FROM AUTHOR]

The article discusses the specific risks associated with people with a learning disability are physically restrained. Several conditions considered for restrictive physical interventions are cited including respiratory disorder, weight, musculoskeletal problems, and cardiovascular disorders. It is suggested that restraint should be used only in a short duration and risk assessment should be carried out to determine the type and level of physical intervention.

The article presents information on a study which determines how the use of seclusion and restraint creates significant risks for people with psychiatric disabilities. The study findings suggest that seclusion and restraint are among the most controversial procedures used in the mental health field. The use of seclusion is a political and economic issue that affects consumers, staff, provider organizations, regulatory agencies and federal legislators.

Aims: The aim of this review was to assess whether restraint and seclusion are safe and effective interventions for the short-term management of disturbed/violent behaviour. Staff and service user perspectives on the use of these interventions were also considered. The review was undertaken as part of the development process for a national guideline on the short-term management of disturbed/violent behaviour in adult psychiatric inpatient settings and emergency departments in the United Kingdom. Method: An exhaustive literature search was undertaken. Systematic reviews, before and after studies, as well as qualitative studies were included. Searches were run from 1985 to 2002. Findings: Thirty-six eligible studies were identified. However, none were randomised controlled trials. Most of the included studies had many limitations, such as small sample sizes, confounders not adequately accounted for, potential selection bias, poorly reported results, and lack of clarity as to whether mechanical restraints were used. This review must therefore be viewed as a mapping exercise, which illustrates the range and quality of studies that have been undertaken in this area to date. Conclusions and Implications for Practice: Insufficient evidence is available to determine whether seclusion and restraint are safe and/or effective interventions for the short-term management of disturbed/violent behaviour in adult psychiatric inpatient settings. These interventions should therefore be used with caution and only as a last resort once other methods of calming a situation and/or service user have failed. Worldviews on Evidence-Based Nursing 2006; 3(1):8-18 [ABSTRACT FROM AUTHOR]

The physical restraint of a disturbed person is a subject constant of psychiatry and is a challenge that particularly faces nurses working in acute inpatient settings. While other approaches to psychiatric treatment have been discarded (e.g. punishment, blood letting, trepanation, deep insulin therapy and so on) or evolved into new treatments (the use of medication), the act of physical restraint has remained largely unmodified. Given the ubiquity of physical restraint in psychiatry, particularly as a nursing procedure, the absence of a sustained body of research is notable. This essay examines some of the historical underpinnings of the use of restraint in psychiatry brought into sharp focus by the David Bennett Inquiry Report (2003) and the National Institute of Clinical Effective (NICE) guidelines (2005) on the management of violence. [ABSTRACT FROM AUTHOR]

There are a great many people with mental health problems receiving treatments that are aimed primarily at managing aggressive or challenging behaviours by means of sedation, seclusion or restraint. The management of these behaviours is frequently justified under Part IV of the Mental Health Act 1983, which permits treatments -- without consent if necessary -- for a person's mental disorder. Alternatively, the behaviours have been managed at common law on the basis that the patient is incapable of giving a legally effective consent to behaviour management and the interventions are considered to be in the person's best interests. This article considers the management of difficult behaviours in adults with mental health problems. This issue is particularly timely as there have been a considerable number of legal challenges in this area in recent years. This article reviews the practical contexts in which behaviour management, which here covers sedation, seclusion and restraint, is used with adults with mental health problems and explores the legal justifications for these interventions. Although the justification for the management of challenging behaviours is frequently asserted (or, more likely, presumed) to be therapeutic, a review of the research literature and recent case law casts doubt on the credibility of this therapeutic justification. [ABSTRACT FROM AUTHOR]

The practice of physical restraint techniques in the management of disturbed behaviour is a significant part of the role of mental health nurses, particularly in Psychiatric Intensive Care Units (PICUs). Debate about what constitutes good practice is intense, and the subject of recently issued guidelines by National Institute for Mental Health in England. However, the contribution of other forms of conflict management techniques has tended to be ignored. The purpose of this study was to identify, describe and categorize coercive manoeuvres used by nurses, and to examine the circumstances and appropriateness of their use. Non-participant observation of verbal and non-verbal interaction between patients and nurses during conflict situations was undertaken on one PICU. The critical incidents observed were identified, categorized and systematically recorded. Nurses used a variety of low level physical and interactional manoeuvres in order to manage patients' disturbed and resistive behaviour. These manoeuvres were seldom recorded, discussed or reviewed, although they were frequently used to manage critical conflict situations. These manoeuvres have neither been previously described nor evaluated. They may, in some cases, be useful substitutes for actual restraint, alternatively they may, in some cases, be judged undesirable. It is not known how widespread these practices are in acute psychiatry. [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]