Participation in Post Incident Reviews after Restraint in Mental Health Services: A qualitative study

Abstract

Background: Evaluation of all kinds of use of force in mental health services was mandated by law in Norway in 2017. Debriefing, or “Post Incident reviews” (PIRs), have been implemented in several western countries since early 2000, often as one part of Seclusion and Restraint (S/R) reduction projects. The factual or theoretical basis of PIR’s is, however, scarce despite the growing focus on prevention of harm and use of restraint in mental health services. Aims: The overall aim of this thesis was to explore PIRs’ potential to promote improvement in terms of human values like participation, influence and collaboration, according to the body of scientific knowledge and experiences developed by care receivers and care providers. The study consisted of four steps. The specific aim of step 1 was to explore the body of scientific literature regarding PIRs. Based on the findings in step 1, the specific aim of step 2 was to explore professionals’ experiences and considerations with PIRs’ after having used physical and mechanical restraints in a Norwegian context. Step 3 was to explore patients’ experiences and considerations with PIRs’ after having physical and mechanical restraints applied to them in a Norwegian context. Step 4 was a synthesizing analysis of the results to summarize the findings regarding PIRs related to scientific knowledge and experiences from care receivers and care providers. Methods: This thesis has a phenomenological-hermeneutic approach with an explorative design. Data were collected by means of the three sub-studies (Articles I, II and III) which contain a scoping review of 12 scientific publications and in-depth interviews with 19 multidisciplinary care providers and 10 patients. Data analyses methods include narrative descriptions (Article I and III) and qualitative content analyses (Article I, II and III). Findings: Article I reports findings from a scoping review where the aim was to identify the prevailing knowledge basis of PIRs. PIRs were often found to be one of several components in seclusion and restraint (S/R) reduction programs, but there was no significant outcome related to PIRs alone. Patients and care providers reported participation in PIRs to be an opportunity to review restraint events they would not have had otherwise, to promote patients’ personal recovery processes and stimulate professional reflection on organizational development and care. The review revealed, however, a knowledge gap; patients’ and care providers’ experiences and considerations of PIRs were scarcely explored. Consequently, the findings provided the basis for article II and III. Article II reports care providers’ experiences and considerations of PIRs. Main theme 1 was PIRs’ potential to improve the quality of care based on knowledge about other perspectives and solutions, increased professional and ethical awareness and emotional and relational processing. Main theme 2 was struggling to get a hold on patients’ voices in the PIRs. Care providers considered that issue to be attributable to the patients conditions, the care providers’ safety and skills and the characteristics of institutional and cultural conditions. Article III reports patients’ experiences and considerations of PIRs. The findings resulted in two overarching themes: (1)‘PIRs as an arena for recovery promotion based on experiences of being strengthened, developing new coping strategies and processing the restraint event’ and (2)‘PIRs as continuation of coercive contexts based on experiencing PIRs as meaningless, feeling objectified and longing for living communication and closeness. Conclusion: The three sub-studies represented different knowledge sources as scientific knowledge and experiences from care receivers and care providers and were thus parts of a larger whole. The findings show that PIRs can be an appropriate and valuable tool both to patients and care providers as PIRs were found to 1) promote the patients’ personal recovery processes, (2) improve the quality of care and (3) facilitate processing of the restraint incident. The thesis’ main findings of PIRs between authoritarian and dialogical approaches point to both the procedure’s possibilities and limitations. The study identified pitfalls that may influence patients’ active participation in the PIRs. The practice of implementing PIRs as an isolated procedure, and thus not a part of a S/R reduction program, as well as unresolved care philosophies in the services seem to be limitations with respect to the Norwegian authorities’ objectives with the procedure. Conducting PIRs in services that base their practices on human care philosophies and values in line with care ethics, that is, acknowledging the stakeholders’ vulnerability and the power-dependence imbalance, may support and empower both patients’ and care providers’ participation and collaboration and thus the patients’ influence in the encounters.