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Non-pharmacological interventions to reduce restrictive practices in adult mental health inpatient settings: the COMPARE systematic mapping review
Abstract and Figures
Objectives
The study aimed to provide a mapping review of non-pharmacological interventions to reduce restrictive practices in adult mental health inpatient settings; classify intervention components using the behaviour change technique taxonomy; explore evidence of behaviour change techniques and interventions; and identify the behaviour change techniques that show most effectiveness and those that require further testing.
Background
Incidents involving violence and aggression occur frequently in adult mental health inpatient settings. They often result in restrictive practices such as restraint and seclusion. These practices carry significant risks, including physical and psychological harm to service users and staff, and costs to the NHS. A number of interventions aim to reduce the use of restrictive practices by using behaviour change techniques to modify practice. Some interventions have been evaluated, but effectiveness research is hampered by limited attention to the specific components. The behaviour change technique taxonomy provides a common language with which to specify intervention content.
Design
Systematic mapping study and analysis.
Data sources
English-language health and social care research databases, and grey literature, including social media. The databases searched included British Nursing Index (BNI), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CCRCT), Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE), EMBASE, Health Technology Assessment (HTA) Database, HTA Canadian and International, Ovid MEDLINE ® , NHS Economic Evaluation Database (NHS EED), PsycInfo ® and PubMed. Databases were searched from 1999 to 2019.
Review methods
Broad literature search; identification, description and classification of interventions using the behaviour change technique taxonomy; and quality appraisal of reports. Records of interventions to reduce any form of restrictive practice used with adults in mental health services were retrieved and subject to scrutiny of content, to identify interventions; quality appraisal, using the Mixed Methods Appraisal Tool; and data extraction, regarding whether participants were staff or service users, number of participants, study setting, intervention type, procedures and fidelity. The resulting data set for extraction was guided by the Workgroup for Intervention Development and Evaluation Research, Cochrane and theory coding scheme recommendations. The behaviour change technique taxonomy was applied systematically to each identified intervention. Intervention data were examined for overarching patterns, range and frequency. Overall percentages of behaviour change techniques by behaviour change technique cluster were reported. Procedures used within interventions, for example staff training, were described using the behaviour change technique taxonomy.
Results
The final data set comprised 221 records reporting 150 interventions, 109 of which had been evaluated. The most common evaluation approach was a non-randomised design. There were six randomised controlled trials. Behaviour change techniques from 14 out of a possible 16 clusters were detected. Behaviour change techniques found in the interventions were most likely to be those that demonstrated statistically significant effects. The most common intervention target was seclusion and restraint reduction. The most common strategy was staff training. Over two-thirds of the behaviour change techniques mapped onto four clusters, that is ‘goals and planning’, ‘antecedents’, ‘shaping knowledge’ and ‘feedback and monitoring’. The number of behaviour change techniques identified per intervention ranged from 1 to 33 (mean 8 techniques).
Limitations
Many interventions were poorly described and might have contained additional behaviour change techniques that were not detected. The finding that the evidence was weak restricted the study’s scope for examining behaviour change technique effectiveness. The literature search was restricted to English-language records.
Conclusions
Studies on interventions to reduce restrictive practices appear to be diverse and poor. Interventions tend to contain multiple procedures delivered in multiple ways.
Future work
Prior to future commissioning decisions, further research to enhance the evidence base could help address the urgent need for effective strategies. Testing individual procedures, for example, audit and feedback, could ascertain which are the most effective intervention components. Separate testing of individual components could improve understanding of content and delivery.
Study registration
The study is registered as PROSPERO CRD42018086985.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research ; Vol. 9, No. 5. See the NIHR Journals Library website for further project information.
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... Additionally, in an acute forensic mental health unit for women in Australia, researchers tested a protocol designed to prioritise less restrictive interventions for preventing aggression, and MR rates were reduced following its introduction [22]. Useful interventions to reduce the use of MR have been reported to include the predefined programmes 'Six Core Strategies' and 'Safewards' [23,24]. In a recent comprehensive review of 221 records, Baker et al. [23] identified 150 unique interventions aimed primarily at reducing seclusion and/or restraint (e.g. ...
... Useful interventions to reduce the use of MR have been reported to include the predefined programmes 'Six Core Strategies' and 'Safewards' [23,24]. In a recent comprehensive review of 221 records, Baker et al. [23] identified 150 unique interventions aimed primarily at reducing seclusion and/or restraint (e.g. mechanical, physical or chemical restraint) in adult mental health inpatient settings, spanning acute, forensic and intensive care units. ...
... However, despite the above initiatives, the literature on such interventions in mental health remains diverse, often containing multiple components delivered in various ways, and vary in scope and quality. This diversity in interventions poses challenges in identifying the most effective intervention strategies [17,[23][24][25]. Therefore, as suggested by others [23,26], although evidence-based interventions to reduce MR use are likely to include multiple components rather than individual approaches, mental health practice should pay more attention to examining the acceptance of the latter when appropriate to generate the best applicable evidence and understanding of their use, even if they are used in a range of strategies. ...
Purpose:
To explore mental health staff's responses towards interventions designed to reduce the use of mechanical restraint (MR) in adult mental health inpatient settings.
Methods:
We conducted a cross-sectional, questionnaire-based survey. The questionnaire, made available online via REDCap, presented 20 interventions designed to reduce MR use. Participants were asked to rate and rank the interventions based on their viewpoints regarding the relevance and importance of each intervention.
Results:
A total of 128 mental health staff members from general and forensic mental health inpatient units across the Mental Health Services in the Region of Southern Denmark completed the questionnaire (response rate = 21.3%). A total of 90.8% of the ratings scored either 'agree' (45.2%) or 'strongly agree' (45.6%) concerning the relevance of the interventions in reducing MR use. Overall and in the divided analysis, interventions labelled as 'building relationship' and 'patient-related knowledge' claimed high scores in the staff's rankings of the interventions' importance concerning implementation. Conversely, interventions like 'carers' and 'standardised assessments' received low scores.
Conclusions:
The staff generally considered that the interventions were relevant. Importance rankings were consistent across the divisions chosen, with a range of variance and dispersion being recorded among certain groups.
... Mechanical restraint (MR) is a commonly used restrictive practice in mental health to immobilise or restrict people's movement in response to violent and aggressive behaviour (National Institute for Health and Care Excellence, 2015). It involves and is defined as the use of equipment, such as belts, straps or cuffs, by trained staff (Baker et al., 2021;Völlm & Nedopil, 2016). However, compared to holding, forced medication or other restrictive practices, MR is especially associated with traumatic experiences for those involved, and psychological and physiological adverse outcomes have been reported, such as re-traumatisation, physical injuries, venous thromboembolism and death (Aguilera-Serrano et al., 2018;Cusack et al., 2018;Kersting et al., 2019;Rakhmatullina et al., 2013;Tingleff et al., 2017). ...
... Thus, a focus on minimising the time people spend in MR is important. Ideally, interventions that reduce both the incidence of and time in MR simultaneously may be beneficial (Baker et al., 2021;Flammer et al., 2021;Steinert et al., 2008). ...
... According to the JBI, at least two researchers are recommended to reduce the risk of bias in the review process (Aromataris & Munn, 2020). In addition to the limitations in these reviews, it may be difficult to tease out evidence-based interventions on MR reduction specifically from other research because different types of restraint, for example, mechanical, chemical and manual, tend to be included without findings for each type being independently reported (Baker et al., 2021;Pedersen et al., 2023;Raveesh et al., 2019). ...
Mechanical restraint is a commonly used restrictive practice worldwide, although reducing its use is an international priority. Interventions to reduce mechanical restraint are needed if reducing mechanical restraint is to succeed. Therefore, this systematic review aimed to examine evaluated evidence‐based interventions that seek to reduce the incidence of and/or time in mechanical restraint in adult mental health inpatient settings. The JBI framework was used to guide this systematic review. The search strategy included peer‐reviewed primary research literature published between 1999 and 2023. Two authors independently conducted the systematic search, selection process and data extraction process. Forty‐one studies were included in this review. Using content analysis, we grouped interventions into four categories: (I) calm‐down methods, (II) staff resources, (III) legal and policy changes and (IV) changing staff culture. Interventions to reduce mechanical restraint in adult mental health inpatient settings have shown some promise. Evidence suggests that a range of interventions can reduce the incidence of and/or time in mechanical restraint. However, controlled trials were lacking and consensus was lacking across studies. Furthermore, specific findings varied widely, and reporting was inconsistent, hampering the development of interventions for this issue. Further research is needed to strengthen the evidence base for reducing mechanical restraint in mental health inpatient settings.
... Instead, as noted, relatively significant resources have been devoted over the past twenty years to understanding why coercion happens and how it can be avoided. Baker et al. [101] estimate that the amount of research conducted on this topic doubled across the first two decades of the current century. This research is often then rapidly and rigorously translated into practical guidance for clinicians operating on the front line. ...
... This umbrella review of 23 primary studies published since 1996 in multiple languages synthesised the findings from existing systematic reviews and provides the most precise estimate of effect sizes for various interventions currently available. Thirdly, Baker et al. [101] conducted a mapping review which analysed the core components of 150 interventions designed to reduce the use of restrictive practices in adult mental health in-patient settings only. Like Gooding et al., they took a broadly inclusive methodological approach toward evaluation studies using any research design and published in English from 1999 onwards. ...
... In combination, the three reviews identify a huge array of interventions which have been developed with some intention or potential to reduce coercion in either in-patient or community settings. In combination, Gooding et al. [104] and Baker et al. [101] specify over 60 distinct interventions. Many interventions in this array, it must be said, are similar approaches with different packaging, which supports the approach adopted by Baker et al. [101] to uncover the core components across the huge diversity of available in-patient programmes. ...
Coercion of service users/patients when receiving care and treatment has been a serious dilemma for mental health services since at least the 18th century, and the debate about how best to minimise or even eradicate compulsion remains intense. Coercion is now, once again and rightly, at the top of the international policy agenda and the COST Action ‘FOSTREN’ is one example of a renewed commitment by service user advocates, practitioners and researchers to move forward in seriously addressing this problem. The focus of service improvement efforts has moved from pure innovation to practical implementation of effective interventions based on an understanding of the historical, cultural and political realities in which mental health services operate. These realities and their impact on the potential for change vary between countries across Europe and beyond. This article provides a novel overview by focusing on the historical, cultural and political contexts which relate to successful implementation primarily in Europe, North America and Australasia so that policy and practice in these and other regions can be adopted with an awareness of these potentially relevant factors. It also outlines some key aspects of current knowledge about the leading coercion-reduction interventions which might be considered when redesigning mental health services.
... Their use may infringe human rights (National Institute for Health and Care Excellence, 2015), and additional negative consequences have been reported, both for those subjected to restrictive practices and the staff involved (Beames & Onwumere, 2021). Consequently, attempts have been made to reduce such strategies, mainly focusing on seclusion/restraint (Baker et al., 2021). Nevertheless, most mental health laws accept staff's use of restrictive practices as a last resort in cases of violence and aggression (Maguire et al., 2021;Völlm & Nedopil, 2016) in an attempt to prevent people from harming themselves or others (Pedersen, 2020;Power et al., 2020). ...
... Nevertheless, most mental health laws accept staff's use of restrictive practices as a last resort in cases of violence and aggression (Maguire et al., 2021;Völlm & Nedopil, 2016) in an attempt to prevent people from harming themselves or others (Pedersen, 2020;Power et al., 2020). While restrictive practices have been investigated and debated for decades, rapid tranquillization seems to have eluded attention and has been studied with varying clarity (Baker et al., 2021;Hu et al., 2019;Pedersen et al., 2022). Rapid tranquillization is the coercive administration of acute calming medication, typically by intramuscular injection (National Institute for Health and Care Excellence, 2015; Völlm & Nedopil, 2016). ...
... As shown in Table 2, research has been conducted mainly in general mental health settings, with only one study from forensic mental health. This distribution of settings was not surprising as it is supported by recent research analysis within restrictive practice use (Baker et al., 2021;Pedersen et al., 2022). However, people in forensic mental health are hospitalized in restrictive settings where the level of conflict and use of restrictive practices may be particularly high (Pedersen, 2020;Völlm & Nedopil, 2016). ...
Rapid tranquillization is a restrictive practice that remains widely used in mental health inpatient settings worldwide. Nurses are the professionals most likely to administer rapid tranquillization in mental health settings. To improve mental health practices, an enhanced understanding of their clinical decision-making when using rapid tranquillization is, therefore, important. The aim was to synthesize and analyse the research literature on nurses' clinical decision-making in the use of rapid tranquillization in adult mental health inpatient settings. An integrative review was conducted using the methodological framework described by Whittemore and Knafl. A systematic search was conducted independently by two authors in APA PsycINFO, CINAHL Complete, Embase, PubMed and Scopus. Additional searches for grey literature were conducted in Google, OpenGrey and selected websites, and in the reference lists of included studies. Papers were critically appraised using the Mixed Methods Appraisal Tool, and the analysis was guided by manifest content analysis. Eleven studies were included in this review, of which nine were qualitative and two were quantitative. Based on the analysis, four categories were generated: (I) becoming aware of situational changes and considering alternatives, (II) negotiating voluntary medication, (III) administering rapid tranquillization and (IV) being on the other side. Evidence suggests that nurses' clinical decision-making in the use of rapid tranquillization involved a complex timeline with various impact points and embedded factors that continuously influenced and/or were associated with nurses' clinical decision-making. However, the topic has received scant scholarly attention, and further research may help to characterize the complexities involved and improve mental health practice.
... In the updated search (2022), of 2695 hits from the updated search, 29 had theoretical components , including 4 reviews [217,218,221,233] and 14 non-maternity controlled studies with at least one measure of verbal or physical abuse [242][243][244][245][246][247][248][249][250][251][252][253][254][255] (Fig 2). ...
... Six of these were controlled studies, based in emergency/ITU/critical care [246,253,254] inpatient geriatric care [243]; a youth behavioural unit [247] and adult psychiatric care [255]. Three quantitative reviews were included [242,245,252] and their reference lists generated five of the included primary studies [244,[248][249][250][251]. Two of the included studies could be metaanalysed [248,253]. ...
... The three included reviews of controlled studies [242,245,252] and two of the primary controlled papers [243,244] also included some theory. They are included in the analysis of theory papers, resulting in a total of 34 papers with theoretical components. ...
Despite global attention, physical and verbal abuse remains prevalent in maternity and newborn healthcare. We aimed to establish theoretical principles for interventions to reduce such abuse. We undertook a mixed methods systematic review of health and social care literature (MEDLINE, SocINDEX, Global Index Medicus, CINAHL, Cochrane Library, Sept 29th 2020 and March 22nd 2022: no date or language restrictions). Papers that included theory were analysed narratively. Those with suitable outcome measures were meta-analysed. We used convergence results synthesis to integrate findings. In September 2020, 193 papers were retained (17,628 hits). 154 provided theoretical explanations; 38 were controlled studies. The update generated 39 studies (2695 hits), plus five from reference lists (12 controlled studies). A wide range of explicit and implicit theories were proposed. Eleven non-maternity controlled studies could be meta-analysed, but only for physical restraint, showing little intervention effect. Most interventions were multi-component. Synthesis suggests that a combination of systems level and behavioural change models might be effective. The maternity intervention studies could all be mapped to this approach. Two particular adverse contexts emerged; social normalisation of violence across the socio-ecological system, especially for 'othered' groups; and the belief that mistreatment is necessary to minimise clinical harm. The ethos and therefore the expression of mistreatment at each level of the system is moderated by the individuals who enact the system, through what they feel they can control, what is socially normal, and what benefits them in that context. Interventions to reduce verbal and physical abuse in maternity care should be locally tailored, and informed by theories encompassing all socio-ecological levels, and the psychological and emotional responses of individuals working within them. Attention should be paid to social normalisation of violence against 'othered' groups, and to the belief that intrapartum maternal mistreatment can optimise safe outcomes.
... The United Nations Convention on the Rights of Persons with Disabilities emphasizes that the human rights of people subjected to different measures of restraint in psychiatric treatment settings are at considerable risk (1). There is a general consensus that restraint should only be considered as a last resort measure and governed by stringent regulations that clearly define when it may be applied (2)(3)(4)(5). Reducing the use of restraint has become a priority in the mental health-care systems of many countries (2,3). Though to date only partially realized, the development of preventive strategies is endorsed with virtual unanimity (6)(7)(8)(9). ...
... There is a general consensus that restraint should only be considered as a last resort measure and governed by stringent regulations that clearly define when it may be applied (2)(3)(4)(5). Reducing the use of restraint has become a priority in the mental health-care systems of many countries (2,3). Though to date only partially realized, the development of preventive strategies is endorsed with virtual unanimity (6)(7)(8)(9). ...
... Value of p according to χ 2 test.2 Effect sizes according to phi or V.3 Value of p according to two-sided t-test for independent samples.4 Effect sizes for t-test. ...
Introduction
The use of restraint as a means of managing patients is considered a critical factor that interferes with recovery. Strategies to create a less restrictive environment within psychiatric facilities are therefore eagerly sought. Peer support workers (PSWs) are increasingly employed in mental health settings. The prevailing theory is that PSWs have the potential to contribute to conflict and restraint prevention efforts in acute psychiatric wards. However, to date, research in support of this claim remains limited.
Objective
The present study aimed at assessing the effectiveness of employing peer support workers with regard to reducing the use of restraint.
Methods
This prospective controlled pre–post study sought to evaluate the implementation of peer support in one locked ward compared to treatment as usual (TAU) with no implementation of peer support in a second locked ward of a psychiatry department in Berlin, Germany. The pre–post comparison was planned to consist of two assessment periods of 3 months each, taking place directly before and after peer support implementation or TAU. Both assessments were extended to a period of 6 months, before and after the initially planned 12-month implementation process, in order to balance the effects of disruptions and of the COVID-19 pandemic. Using routine data, the proportion, frequency, and duration of mechanical restraint, forced medication as well as mechanical restraint in combination with forced medication, were evaluated.
Results
In the control group, an increase in the proportion of patients subjected to measures of restraint was found between pre- and post-assessment, which was accompanied by a further increase in the mean number of events of restraint per patient within this group. In the intervention group, no significant change in the application of restraint was observed during the study period.
Discussion
There is some indication that peer support may be protective with regard to restraint in acute wards. However, our study faced major challenges during the implementation process and the post-assessment period, such as COVID-19 and staff reorganization. This may have led to peer support not reaching its full potential. The relationship between the implementation of peer support and the use of restraint therefore merits further investigation.
... There are systematic reviews of longerterm NPIs started in the ED that are then continued in the outpatient setting, despite the very great differences between environments (Chaudhary et al., 2020;Johnston et al., 2019;McCabe et al., 2018;Ougrin et al., 2012;Wilson et al., 2020) which indicate that NPIs such as green or gold card clinics and postcards to people after self-harm attempts may show potential in reducing suicide and suicide attempts. Other reviews have evaluated environmental interventions in the ED (MohammadiGorji et al., 2021) showing that environment plays a central role in mitigating aggression, service-wide interventions (Baker et al., 2021) showing great need for better systems to manage restrictive practices, psychological therapies on adult inpatient units (Jacobsen et al., 2018) showing that inpatient research lacks rigour and organisation, and the evidence for environment, policy and practice changes addressed acute severe behavioural disturbance in the ED (Weiland et al., 2017) demonstrating a deficit in research surrounding acute severe behavioural disturbance. ...
... However, several interventions show promise, such as short admissions with accompanying psychotherapies, SMRs and suicide-specific interventions. Interestingly, reviews have found a similar lack of structure in the fields of managing restrictive practice (Baker et al., 2021), inpatient NPIs (Jacobsen et al., 2018) and acute severe behavioural disturbance (Weiland et al., 2017). This could be attributed to the inherent challenges of conducting research in emotionally charged and hectic environments. ...
Objective
Heterogeneous brief non-pharmacological interventions and guidelines exist to treat the burgeoning presentations to both emergency department and inpatient settings, for those in a crisis of mental ill-health. We systematically reviewed the literature to create a taxonomy of these brief non-pharmacological interventions, and review their evaluation methods and effectiveness.
Method
We conducted a systematic review across Cochrane, CINAHL, DARE, Embase, MEDLINE, PsycINFO databases. Studies meeting quality criteria, using Joanna Briggs Institute tools, were eligible. Interventions were categorised, and outcomes synthesised.
Results
Thirty-nine studies were included: 8 randomised controlled trials, 17 quasi-experimental, 11 qualitative studies, and 3 file audits. Taxonomy produced six coherent intervention types: Skills-focussed, Environment-focussed, Special Observation, Psychoeducation, Multicomponent Group and Multicomponent Individual. Despite this, a broad and inconsistent range of outcome measures reflected different outcome priorities and prevented systematic comparison of different types of intervention or meta-analysis. Few brief non-pharmacological interventions had consistent evidential support: sensory modulation rooms consistently improved distress in inpatient settings. Short admissions may reduce suicide attempts and readmission, if accompanied by psychotherapy. Suicide-specific interventions in emergency departments may improve depressive symptoms, but not suicide attempt rates. There was evidence that brief non-pharmacological interventions did not reduce incidence of self-harm on inpatient wards. We found no evidence for frequently used interventions such as no-suicide contracting, special observation or inpatient self-harm interventions.
Conclusion
Categorising brief non-pharmacological interventions is feasible, but an evidence base for many is severely limited if not missing. Even when there is evidence, the inconsistency in outcomes often precludes clinicians from making inferences, although some interventions show promise.
... There is a welcome growth in safety research in mental health care. This has tended towards a focus on service environments (Berzins et al, 2020), service processes (Berzins et al, 2018) and, inpatient settings, and the interventions used by staff to prevent harm and promote safety (Baker et al, 2021). ...
The person-centred, safety planning group was established in 2020 to develop new approaches to understanding risk and safety and how this this may be managed in a meaningful, co-produced and inclusive way within mental health care. The group includes representation from each Health Board in Wales, together with a number of national agencies. The principles underpinning the work include: • Ensuring safety is the central thread of risk assessment and risk management. • Ensuring opportunities for involvement, contribution and co-production are given at each step of the process used. • Avoiding simplistic approaches to risk assessment and management processes whilst reducing the complexity within them • Capitalising on the wealth of existing research, knowledge, and practice in relation to risk assessment, risk management and safety planning. This evidence briefing is one outcome of this work of this group and is focused on summarising the rationale and providing an initial review of the evidence base for adopting person-centred safety planning for people using secondary mental health services.
... for the implementation has high acuity and therefore there is not enough time or resources for adopting new interventions (13). Previous systematic reviews on this topic have focused on the question of effectiveness of coercion reduction programs (15) rather than implementation issues, giving an overview of existing interventions (16,17), or focusing on single programs, such as Safewards (13). There have been systematic implementation reviews in mental health services such as one that looked at effective strategies when implementing trauma-informed care in youth inpatient psychiatric and residential treatment settings (18). ...
Introduction
Implementation models, frameworks and theories (hereafter tools) provide researchers and clinicians with an approach to understand the processes and mechanisms for the successful implementation of healthcare innovations. Previous research in mental health settings has revealed, that the implementation of coercion reduction programs presents a number of challenges. However, there is a lack of systematized knowledge of whether the advantages of implementation science have been utilized in this field of research. This systematic review aims to gain a better understanding of which tools have been used by studies when implementing programs aiming to reduce formal coercion in mental health settings, and what implementation outcomes they have reported.
Methods
A systematic search was conducted using PubMed, CINAHL, PsycINFO, Cochrane, Scopus, and Web of Science. A manual search was used to supplement database searches. Quality appraisal of included studies was undertaken using MMAT—Mixed Methods Appraisal Tool. A descriptive and narrative synthesis was formed based on extracted data. Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed in this review.
Results
We identified 5,295 references after duplicates were removed. Four additional references were found with a manual search. In total eight studies reported in nine papers were included in the review. Coercion reduction programs that were implemented included those that were holistic, and/or used professional judgement, staff training and sensory modulation interventions. Eight different implementation tools were identified from the included studies. None of them reported all eight implementation outcomes sought from the papers. The most frequently reported outcomes were acceptability (4/8 studies) and adaptation (3/8). With regards to implementation costs, no data were provided by any of the studies. The quality of the studies was assessed to be overall quite low.
Discussion
Systematic implementation tools are seldom used when efforts are being made to embed interventions to reduce coercive measures in routine mental health care. More high-quality studies are needed in the research area that also involves perspectives of service users and carers. In addition, based on our review, it is unclear what the costs and resources are needed to implement complex interventions with the guidance of an implementation tool.
Systematic review registration
[Prospero], identifier [CRD42021284959].
Background:
Physical restraint is a coercive intervention used to prevent individuals from harming themselves or others. However, serious adverse effects have been reported. Minimising the use of restraint requires a multimodal approach to target both organisational and individual factors. The 'Six Core Strategies' developed in America, underpinned by prevention and trauma informed principles, is one such approach.
Objective:
An adapted version of the Six Core Strategies was developed and its impact upon physical restraint usage in mental health Trusts in the United Kingdom evaluated. This became known as 'REsTRAIN YOURSELF. The hypothesis was that restraint would be reduced by 40% on the implementation wards over a six-month period.
Design:
A non-randomised controlled trial design was employed.
Setting:
Fourteen, adult, mental health wards from seven mental health hospitals in the North West of England took part in the study. Two acute care wards were targeted from all eligible acute wards within each site in negotiation with each Trust. The intervention wards (total n = 144 beds, mean = 20.1 beds per ward) and control wards (total n = 147 beds, mean = 21.0 beds per ward) were primarily mixed gender but included single sex wards also (2 female-only and 1 male-only in each group). All wards offered pharmacological and psychosocial interventions over short admission durations (circa 15 days) for patients with a mixture of enduring mental health problems.
Method:
As part of a pre and post-test method, physical restraint figures were collected using prospective, routine hospital records before and 6 months after the intervention. Restraint rates on seven wards receiving the REsTRAIN YOURSELF intervention were compared with those on seven control wards over three study phases (baseline, implementation and adoption).
Results:
In total, 1680 restraint incidents were logged over the study period. The restraint rate was significantly lower on the intervention wards in the adoption phase (6.62 events/1000 bed-days, 95% CI 5.53-7.72) compared to the baseline phase (9.38, 95% CI 8.19-10.55). Across all implementation wards there was an average reduction of restraint by 22%, with some wards showing a reduction of 60% and others less so (8%). The association between ward type and study phase was statistically significant.
Conclusion:
In conclusion, it is possible that reductions in the use of physical restraint are achievable using a model such as the Six Core Strategies. This approach can be adapted for global settings and changes can be sustained over time with continued support.
International efforts to minimize coercive practices include the US Six Core Strategies© (6CS). This innovative approach has limited evidence of its effectiveness, with few robustly designed studies, and has not been formally implemented or evaluated in the UK. An adapted version of the 6CS, which we called ‘REsTRAIN Yourself’ (RY), was devised to suit the UK context and evaluated using mixed methods. RY aimed to reduce the use of physical restraint in mental health inpatient ward settings through training and practice development with whole teams, directly in the ward settings where change was to be implemented and barriers to change overcome. In this paper, we present qualitative findings that report on staff perspectives of the impact and value of RY following its implementation. Thirty‐six staff participated in semi‐structured interviews with data subject to thematic analysis. Eight themes are reported that highlight perceived improvements in every domain of the 6CS after RY had been introduced. Staff reported more positively on their relationships with service users and felt their attitudes towards the use of coercive practices such as restraint were changed; the service as a whole shifted in terms of restraint awareness and reduction; and new policies, procedures, and language were introduced despite certain barriers. These findings need to be appreciated in a context wherein substantial reductions in the use of physical restraint were proven possible, largely due to building upon empathic and relational alternatives. However, yet more could be achieved with greater resourcing of inpatient care.
Literature reviews are an important and popular part of synthesising evidence across a range of disciplines. There are numerous approaches, each with their distinctive features and purposes. The aim of this article is to advance the science of literature reviewing by describing a new form of review: The ‘Focused Mapping Review and Synthesis’ (FMRS). We critique the approach and highlight its similarities and differences in relation to existing review methodologies. There are four key features of FMRS. It: 1) focuses on a defined field of knowledge rather than a body of evidence; 2) creates a descriptive map or topography of key features of research within the field rather than a synthesis of findings; 3) comments on the overall approach to knowledge production rather than the state of the evidence; 4) examines this within a broader epistemological context. The FMRS can be used to answer questions that might not be appropriate for other review types and potentially offers a useful addition to the methodological toolkit of social researchers from multiple disciplines.
Increased presence is more than adding a registered nurse at the end of the hallway. It was evidence of a specific intervention by which nurses became part of the healing environment. Through the introduction of an authentic, caring, and trusting presence in a psychiatric hallway the potential for violence was reduced—highlighting the critical need for nurses to remain grounded, self-aware and cognizant of their strengths and limitations when interacting with patients.
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Background
Violence and aggression are common in inpatient mental health hospital settings and cause problems for staff, patients and organisations. An important factor in treatment efficacy is ward atmosphere, and one element of this is the violence prevention climate.
Objectives
To develop and test the psychometric properties of a new scale to measure perceptions of the violence prevention climate among staff and patients in mental health inpatient settings.
Design
Scale development and cross-sectional validation study. Setting and participants: Three hospital sites within an independent sector provider of secure mental health care. Participants were patients and staff residing in/working on wards in the adult male and female mental health care pathways.
Methods
The study was conducted in three stages: scale development, pilot testing and psychometric evaluation. The scale items were developed from systematic literature review, informant interviews (staff) and focus groups (patients) and expert review. The resulting scale was subject to pilot testing with staff and patients (n = 58 and n = 25). The reliability and validity of the scale was examined by administering it to 326 staff and 95 patients. Exploratory factor analysis was used to establish construct validity, and this was further assessed with Rasch modelling. Internal consistency was assessed by calculation of Cronbach's alpha coefficients. Convergent and discriminant validity were measured by comparing results with existing validated instruments. Temporal stability of the items was assessed using test-retest reliability coefficients.
Results
The VPC-14 is a 14-item scale demonstrating good psychometric properties. Exploratory factor analysis revealed two subscales, staff actions and patient actions, each demonstrating good internal consistency (Cronbach's alpha .89 and .76). All items demonstrated good temporal stability. Rasch modelling confirmed the unidimensionality of the two subscales, and items demonstrated high construct validity. Moderate correlations were found between subscales of the VPC-14 and the EssenCES, whilst no correlations were found with items in the ACMQ, thus demonstrating good convergent and discriminant validity.
Conclusion
The VPC-14 is currently the most robust available measure of the inpatient violence prevention climate. It is quick and easy to administer, considers views of both staff and patients and thus can be introduced as standard practice in a ward setting. Potential uses include tracking the violence prevention climate longitudinally and in evaluation of new policy and procedural interventions.
This paper will attempt to illustrate the use of a kaleidoscope metaphor as a template for the organization and analysis of qualitative research data. It will provide a brief overview of the constant comparison method, examining such processes as categorization, comparison, inductive analysis, and refinement of data bits and categories. Graphic representations of our metaphoric kaleidoscope will be strategically interspersed throughout this paper.
Aims:
Given the importance of addressing provider attitudes toward individuals with unhealthy alcohol use and the current emphasis on person-centered language to help decrease stigma and mitigate negative attitudes, the aim of this study was to evaluate the psychometric properties of a contemporary version of the Alcohol and Alcohol Problems Perception Questionnaire (AAPPQ) that uses person-centered language and addresses the spectrum of alcohol use.
Methods:
The authors created a person-centered version of the AAPPQ (PC-AAPPQ) and conducted a cross-sectional study of its psychometric properties in academic settings in the Northeastern United States. The PC-AAPPQ was administered to 651 nursing students. Reliability analysis of the new instrument was performed using the total sample. Only surveys with complete data (n = 637) were randomly split into two datasets, one used for the exploratory factor analysis (EFA) (n = 310) and the other for confirmatory factor analysis (CFA) (n = 327).
Results:
Compared to all the models generated from the EFA, neither the original six-factor structure nor the five-factor structure was superior to any of the other models. The results indicate that a seven-factor structure with all 30 items is the best fit for the PC-AAPPQ.
Conclusions:
The PC-AAPPQ represents a positive effort to modernize the four-decade-old AAPPQ. This 30-item instrument, which adds one additional subscale, offers a means to assess providers' attitudes using respectful wording that avoids perpetuating negative biases and reinforces efforts to affirm the worth and dignity of the population being treated.
Background: Despite advances in behavioural science, there is no widely shared understanding of the ‘mechanisms of action’ (MoAs) through which individual behaviour change techniques (BCTs) have their effects. Cumulative progress in the development, evaluation and synthesis of behavioural interventions could be improved by identifying the MoAs through which BCTs are believed to bring about change. Purpose: This study aimed to identify the links between BCTs and MoAs described by authors of a corpus of published literature.Methods: Links between BCTs and MoAs were extracted by two coders from 277 behaviour change intervention articles. Binomial tests were conducted to provide an indication of the relative frequency of each link. Results: Of 77 BCTs coded, 70 were linked to at least one MoA. Of 26 MoAs, all but one were linked to at least one BCT. We identified 2636 BCT-MoA links in total (mean number of links per article = 9.56, SD = 13.80). The most frequently linked MoAs were ‘Beliefs about Capabilities’ and ‘Intention’. Binomial test results identified up to five MoAs linked to each of the BCTs (M = 1.71, range: 1-5), and up to eight BCTs for each of the MoAs (M = 3.63, range: 1-8). Conclusions: The BCT-MoA links described by intervention authors and identified in this extensive review present intervention developers and reviewers with a first level of systematically collated evidence. These findings provide a resource for the development of theory-based interventions, and for theoretical understanding of intervention evaluations. The extent to which these links are empirically supported requires systematic investigation.
The aim of this study was to investigate whether the implementation of the Safewards model reduces the frequency of coercive measures in adult psychiatric inpatient units. Data on all coercive measures performed in psychiatric hospitals in the Region of Southern Denmark 1/1/2012-31/3/2017 were collected retrospectively through The Register of Coercive Measures in Psychiatric Treatment. Interrupted time series analysis by segmented regressions with poisson models were performed on overall coercive measures (n = 12,660), mechanical restraint (n = 2948) and forced sedation (n = 4373). A 2% (95% CI: 1%-4%, p < 0.001) decrease per quarter in the frequency of coercive measures and an 11% (95% CI: 8%-13%, p < 0.001) decrease per quarter in the frequency of forced sedation were found after the implementation of the Safewards model. In conclusion, the implementation of the Safewards model in adult psychiatric inpatient units was associated with a decrease in forced sedation and potentially the overall use of coercive measures.
Objective:
To develop and evaluate a new brief self-report measure of satisfaction/quality of life in depressed outpatients.
Methods:
Using the Quality of Life Enjoyment and Satisfaction Questionnaire Short-Form (Q-LES-Q-SF) self-report from Step-1 (n = 2181) of the STAR*D trial, items were selected based on their magnitude of change with treatment and correlation with 16-item Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR16). Psychometric analyses were conducted. Replication of scale performance was assessed with STAR*D Step-2 data (n = 250).
Results:
The 7 items selected ("Mini-Q-LES-Q") rated satisfaction with work, household activities, social and family relations, leisure time activities, daily function and sense of well-being in the past week. This uni-dimensional scale captured 83-94% variance in Q-LES-Q-SF and had acceptable Item Response and Classical Test Theory characteristics. Baseline to exit percent changes in the Mini-Q-LES-Q and the QIDS-SR16 were significantly, modestly related (r = -0.552) (Step-1) and replicated (r = -0.562) (Step-2). The Mini-Q-LES-Q detected the expected improvement in satisfaction/quality of life in acute treatment, yet also identified residual deficits expected in many at acute-phase exit.
Limitations:
Population norms are yet undefined. Concurrent validity with detailed, well-validated scales that assess the seven Quality of Life domains incorporated in the Mini-Q-LES-Q remains unestablished. Sensitivity to symptom changes induced by psychotherapy or somatic therapies or sensitive to the effects of therapies aimed at enhancing quality of life enjoyment and function is unknown.
Conclusion:
The 7-item Mini-Q-LES-Q self-report measure satisfaction/quality of life has acceptable psychometric properties, reflects change with depressive symptom reduction, and detects residual deficits in this key clinical outcome.