Restrictive Practices Research Articles

'It's a Horrible Place to Have a Period': A Survivor-Led Investigation of Experiences of Menstrual Health in Psychiatric Inpatient Settings in England.

This study examined patients' experiences of menstrual health in psychiatric inpatient settings in England as reported by staff and patients. Questionnaires were conducted with 67 staff members and 101 people with lived experience of menstruation and treatment on a psychiatric ward. 10 semi-structured interviews were conducted with people with lived experience. Data were analysed using reflexive thematic analysis. Grouped into overarching themes of institutional and interpersonal environments, four themes were identified: access to menstrual materials; the lack of privacy when menstruating in psychiatric inpatient settings; attitudes and approaches to menstruation; and menstrual support needs and care provision. There was variation among the experiences reported, with some patients receiving dignified care, whilst others described facing 'degrading' and 'dehumanising' treatments and enhanced feelings of shame and embarrassment around menstruation, in comparison with what they usually experience. This appeared to arise due to the interplay between mental health services overlooking menstruation and the overreliance on restrictive practices. These experiences may be understood as menstrual injustices, period poverty,potentially amounting to neglect and posing iatrogenic harms. Participants also discussed how their mental illness and distress, particularly within the context of trauma and/or eating disorders, shaped their menstrual experiences. However, many patients did not receive adequate support in relation to this. Patients' pain and disorder related to menstruation, or gynaecological conditions, was often described as being dismissed by staff or being viewed as beyond the responsibility of mental health services. This study highlighted the urgency for actions to be taken to provide greater support for patients who menstruate in psychiatric inpatient settings.

A Quantitative Study on Parental Influence and Lifestyle Factors in Child Obesity

Child obesity is a growing global health concern, significantly impacting both developed and developing countries. This study examines the influence of parental behaviors and lifestyle factors on child obesity in Keyouqianqi, Inner Mongolia, China. Employing a quantitative research design, data was collected from 50 parents of obese children through structured questionnaires. Statistical analyses revealed significant associations between parental promotion of healthy eating, physical activity encouragement, and lower obesity rates, whereas restrictive feeding practices were linked to higher obesity rates. Lifestyle factors such as high-calorie food consumption, sugary beverage intake, insufficient physical activity, and excessive screen time were also significantly associated with child obesity. The findings underscore the importance of comprehensive interventions addressing both parental behaviors and children's lifestyle choices to combat child obesity effectively.

Use of restrictive practices in approved mental health centres in Ireland: consideration of five years of national data.

To evaluate the rates of use of restrictive practices (RPs), such as seclusion and physical restraint, in approved mental health centres (ACs) in Ireland. Examination of data reported to the regulator of mental health in Ireland, the Mental Health Commission (MHC), and the Health Research Board (HRB). There has been a substantial reduction in RP use in Irish ACs between 2018 and 2022. The MHC welcomes this reduction in RP use and considers several possible reasons for this data.

The management of atopic dermatitis in women of childbearing age: confused terminology, lack of evidence and resulting clinical inertia.

Confusion in definitions, conflicting opinions and limited evidence leave women of childbearing age with eczema, and treating clinicians, vulnerable to restrictive therapeutic practices.

Staff’s understanding of the role of least restrictive practice in the development of obesity in secure psychiatric inpatients

PurposeThis study aims to explore the ethical challenges of managing the weight of psychiatric patients in the least restrictive manner in secure mental health settings and whether these could be considered as a source of moral distress for health practitioners, which may be linked to staff burnout and ultimately lead to suboptimal patient care.Design/methodology/approachA qualitative semi-structured interview study design was used to explore the understanding, views and experiences of six staff members working on two medium-secure wards in a UK mental health hospital using an opportunity sampling technique and Interpretative Phenomenological Analysis.FindingsAnalysis of semi-structured interviews revealed a multitude of moral events that evoked feelings of frustration, powerlessness and anxiety related to the management of obesity in the least restrictive way, which is indicative of moral distress.Research limitations/implicationsDue to the small sample size and the qualitative nature of the research, the findings of this study are of explorative in nature. Further quantitative research would be required to establish a causative link between the ethical challenges associated with obesity management and staff’s moral distress.Practical implicationsAddressing the health-care professionals’ knowledge deficit on how to achieve the right balance in their duty of care through inclusion of bioethics into professional discussions and training could improve staff’s well-being and the organisation’s ethical climate.Originality/valueTo the best of the authors’ knowledge, this is the first qualitative work exploring the role of least restrictive practice in the challenges associated with health promotion within secure psychiatric settings, and the effect these challenges have on mental health staff.

Postdigital Citizen Science and Humanities: Dialogue from the Ground

AbstractWhilst much global research takes place in universities, many researchers in the sciences and humanities do not work within these institutions. Some citizen researchers run their own companies or provide independent consultancy, having left their roles in universities through a conflict of values, where they experienced hostile, hierarchical, or restrictive practices. In a world where many postdigital and biodigital challenges do not sit neatly under one discipline or sector, collaboration with community experts to research potential solutions is crucial, as demonstrated during the Covid-19 pandemic. Universities count knowledge exchange partnerships as a key part of their activities, linked to the United Nations Sustainable Development Goals, yet a closer look at how this works in practice reveals different forms of ‘lockdowns’ that prevent equitable research collaborations. In this collective article, we offer a postdigital perspective on citizen science and humanities research from the ground. This includes a provocation to knowledge-producing institutions via recommendations that emerged from our collective citizen researcher workshop held in Zagreb in Spring 2024. There is now a pressing need to review institutional policies and practices around citizen research, towards more inclusive knowledge exchange partnerships, if we are to collaborate successfully to address many global challenges.

Exploring the Safewards Programme to Reduce Restrictive Practices in Residential Aged Care: Protocol for a Pilot and Feasibility Study.

Restrictive practice use in residential aged care homes internationally is unacceptably high. Although policies and legislation mandate the reduction or elimination of restrictive practices, there remains a gap in knowledge regarding strategies that have been effective in achieving a sustained reduction in restraint use. There is an urgent need to identify effective and feasible interventions that aged care staff can implement in everyday practice to reduce restraint use. Safewards is an evidence-based programme that has demonstrated effectiveness in reducing conflict and restrictive practice use in inpatient psychiatric settings and has the potential to address the issue of restraint use in aged care homes. This study aims to evaluate the feasibility of Safewards in reducing restrictive practices in residential aged care homes. This pilot and feasibility study will adopt a mixed methods process and outcomes evaluation. Safewards will be implemented in two Australian residential aged care homes. The Reach, Effectiveness, Adoption, Implementation and Maintenance framework will be used to evaluate implementation outcomes. Additionally, the Consolidated Framework for Implementation Research will be used to guide qualitative data collection (including semi-structured interviews with residents/family members, aged care leaders and staff) and explain the facilitators and barriers to effective implementation. This study will provide pilot evidence on the feasibility of the Safewards programme in residential aged care homes. Understanding the processes and adaptations for implementing and evaluating Safewards in residential aged care will inform a future trial in aged care to assess its effectiveness. More broadly, the findings will support the implementation of an international aged care policy of reducing restrictive practices in residential aged care. A person with lived experience of caring for someone with dementia is employed as a Safewards facilitator and is a member of the steering committee. Residents and family members will be invited to participate in the project steering committee and provide feedback on their experience of Safewards. ACTRN12624000044527.

Menstruation Related Practices among Adolescent Girls and Women in a Semi-urban Area of Nepal

Background Menstruation is often associated with restrictions from different activities. Studies about extreme form of menstruation practices i.e. “Chhaupadi” have been widely done but other practices have been less studied. Thus, this study aimed to find out the menstruation related practices among adolescent girls and women in secondary schools in a semi-urban community of Nepal. MethodsThis was a descriptive cross-sectional study done at two secondary schools in a semi-urban community of Panauti municipality which were selected purposively. The duration of study was from 31st October 2022 to 15th November, 2022. Total 158 adolescent girls and women present at the study site who have had menarche were included in the study through census sampling. Ethical approval was taken from the Institutional Review Committee [Reference number: 36/22] of Kathmandu University School of Medical Sciences. Self-administered semi-structured questionnaires were used to collect the information.ResultsAmong 158 study participants, menstrual restriction practice was followed by 155(98.66%) and most common restriction was not being allowed to worship or go to worshipping room 150 (96.77%). Most (68.98%) of the study participants said that their mother insisted them to follow such practices.Conclusions Menstruation related practices were common among the study participants and most common form of restriction was not being allowed to worship.

Positive Behaviour Support is effective when implemented correctly: a response to “Restrictive practice – A pathway to elimination” (Spivakovsky, Steele, & Wadiwel, 2023)

Spivakovsky et al. (2023) questioned the effectiveness of Positive Behaviour Support as an intervention for reducing challenging behaviour and the use of restrictive practices as a behaviour management approach. This article responds to their critique. We argue that the literature supports the effectiveness of Positive Behaviour Support when it is properly implemented. As employees of a Positive Behaviour Support service provider, our position is also supported by our experience of the use of Positive Behaviour Support and its beneficial outcomes. To ensure a high level of fidelity in the implementation of Positive Behaviour Support, it needs to align with the elements that underpin Positive Behaviour Support (i.e., elements of applied behaviour analysis, person-centred practice, human rights, system change) rather than simply implementing Positive Behaviour Support to meet existing legislative requirements. In conclusion, when Positive Behaviour Support service provision and implementation in Australia is correctly aligned with the core components of Positive Behaviour Support, positive outcomes for people with disabilities, including a reduction in the use of restrictive practices, can be achieved.

WP2.5 - Impact of repeated phlebotomy in long-stay patients and patients requiring total parenteral nutrition

Abstract Introduction Blood tests are an essential for patient management. Repeated tests can be associated with harm. The study aimed to assess the consequences of repeated phlebotomy in patients with a long hospital stay or requiring total parenteral nutrition (TPN). Methods Retrospective data was collected from general surgical patients with a length of stay (LOS) of at least 14 days, over a period of 6 months. Biochemical parameters including haemoglobin were recorded on day of admission, day 14 and day 21. Complications following phlebotomy were also noted. Results 133 patients were identified. 84 patients had a LOS >21 days. The longest inpatient stay was 92 days. The most common pathologies were related to lower gastrointestinal disease at 45 cases. TPN was required in 35 cases. Average blood loss as a result of blood sampling was 325 ml/admission (105ml-850 ml), with associated average drop in haemoglobin of 20%. In 6 cases, haemoglobin dropped >40%. Rate of testing per admission length was 1every two days. (45 times as a peak) The most common complications noted were technical ( lab errors/ inadequate sampling). Other physical and psychological factors. A Full set of blood tests costs 150£. In our intervention, 4ml paediatric blood vacutainers (to 13 ml adult’s) were trialled in 10 cases. The results were very comparable. Potential 60% reduction in blood loss was noted. Conclusion careful clinical judgment and controlled approach with restricted practice towards phlebotomy is mandatory .It can be harmful, if not clinically required. Plus it’s expensive costs. Paediatric blood vacutainers can be a beneficial alternative in those requiring regular blood sampling.

Data-driven education improves patient blood management: A pilot study

Abstract Introduction: We sought to increase the use of a restrictive transfusion protocol through clinician education and a standard approach to Patient Blood Management (PBM) in our gynecologic oncology service. Optimal PBM requires the consistent application of evidence-based, restrictive transfusion guidelines, however the use of restrictive transfusion is understudied in surgical oncology populations. We hypothesized that provider specific education that includes data derived from their own clinical practice would result in improved compliance current evidence-based transfusion guidelines. Methods: We created an educational activity that described evidence-based restrictive transfusion guidelines followed by data showing providers their own clinical transfusion practice where compliance with restrictive guidelines was poor. After the education, a plan to improve compliance was developed and put into place. Comparison of transfusion practices and complication/morbidity rates before and after the education was performed. Results: During the 18 months post-education the number of RBC units transfused decreased from 316 152, a 57% reduction and monthly transfusion events were reduced by 42% from 12 to 7 per month. The percent of transfusions with a pretransfusion hemoglobin less than 7 g/dL increased from 40% to 56%. The percent of transfusions with a hemoglobin less than 8 g/dL increased to 90%. Finally, the use of single unit transfusions increased from 49 to 85%, a major contributor to the reduction in units transfused. Conclusion: We created a service-specific educational intervention that improved compliance with evidence-based restrictive transfusion practice. This intervention improved provider compliance with lower transfusion thresholds and increased the use of single-unit transfusions.

Re-Examining the Predictive Validity and Establishing Risk Levels for the Dynamic Appraisal of Situational Aggression: Youth Version.

The Dynamic Appraisal of Situational Aggression: Youth Version (DASA:YV) is a brief instrument, most often used by nurses and was specifically designed to assess risk of imminent violence in youth settings. To date, it has been recommended that DASA:YV scores are interpreted in a linear manner, with high scores indicating a greater level of risk and therefore need more assertive and immediate intervention. This study re-analyses an existing data set using contemporary robust data analytic procedures to examine the predictive validity of the DASA:YV, and to determine appropriate risk bands. Mixed effect logistic regression models were used to determine whether the DASA:YV predicted aggression when the observations are correlated. Two approaches were employed to identify and test novel DASA:YV risk bands, where (1) three risk bands as previously generated for the adult DASA were used as a starting point to consider recategorising the DASA:YV into three risk bands, and (2) using a decision tree analysis method known as Chi-square automated interaction detection to produce risk bands. There was no statistically significant difference between a four and three category of risk band. AUC values were 0.85 for the four- and three-category options. A three-category approach is recommended for the DASA:YV. The new risk bands may assist nursing staff by providing more accurate categorisation of risk state. Identification of escalation in risk state may prompt early intervention, which may also prevent reliance on the use of restrictive practices when young people are at risk of acting aggressively.

Damaging dichotomies and confounding contradictions in mental health inpatient nursing: lessons learned from Orwell’s 1984

PurposeThis discursive paper considers the use of restrictive practices in mental health inpatient settings and how these are often prioritised over relational approaches, especially where the diagnostic label of personality disorder intersects with risk.Design/methodology/approachKey concepts from Orwell’s 1984 are studied for their pertinence to mental health inpatient settings, supporting our argument that restrictive practices arise from dichotomous thinking and externalised fears.FindingsDrawing upon Orwellian themes of power, social control and digital surveillance from 1984, the authors highlight the role of fear in perpetuating restrictive practices under a guise of benevolent care in mental health inpatient settings, especially for those who are diagnosed with a personality disorder. A lack of preparedness to work with complexity in such environments, coupled with a deficit in self-reflexivity and critical thinking, can exacerbate challenges.Research limitations/implicationsTo transcend damaging dichotomies and reduce restrictive practices in inpatient settings, the authors make the argument for the adequate preparation and education of the mental health nurse and authentic, collaborative, user-involved care.Originality/valueThe authors use Orwell’s novel to support a critical discourse around those damaging dichotomies and inherent contradictions that contribute to restrictive practice in contemporary mental health settings and to question whose interests’ these restrictive practices serve.

Proposals for revised International Working Group–European LeukemiaNet criteria for anemia response in myelofibrosis

AbstractWith emerging new drugs in myelofibrosis (MF), a robust and harmonized framework for defining the severity of anemia and response to treatment will enhance clinical investigation and facilitate interstudy comparisons. Accordingly, the lead authors on the 2013 edition of the International Working Group–European LeukemiaNet (IWG-ELN) response criteria in MF were summoned to revise their document with the intent to (1) account for gender-specific differences in determining hemoglobin levels for eligibility criteria; (2) revise the definition of transfusion-dependent anemia (TDA) based on current restrictive transfusion practices; and (3) provide a structurally simple and easy to apply response criteria that are sensitive enough to detect efficacy signals (minor response) and also account for major responses. The initial draft of the 2024 IWG-ELN proposed criteria was subsequently circulated around a wider group of international experts and their feedback incorporated. The proposed articles include new definitions for TDA (≥3 units in the 12 weeks before study enrollment) and hemoglobin thresholds for eligibility criteria (<10 g/dL for women and <11 g/dL for men). The revised document also provides separate (TDA vs non-TDA) and graded (major vs minor response) response criteria while preserving the requirement for a 12-week period of screening and observation on treatment.

How neoliberal individualism led the Disability Royal Commission astray

People with intellectual disabilities can be abused in all settings: homes, communities, and services. Reducing this abuse requires attention be paid to people who are engaged with people with intellectual disabilities, who were largely overlooked by a neoliberal inquiry focused on individuals. Displacing neoliberalism has been further impeded by its recent combination with social media, which has engendered “cultural homogenisation”: the further spread and sustenance of the same ideas. This article aims to offer a fundamental critique of the Disability Royal Commission’s (the Commission) inquiry by revealing the way neoliberal ideology has shaped its recommendations; and to identify positive alternatives. Arguments: (1) Neoliberal individualism is a powerful but invisible doctrine. Its focus on choice and autonomy has generated concern to provide accessible information, irrespective of its feasibility; and concern to eliminate restrictive practices, irrespective of equally important needs of staff and parents. (2) “Datafication” intended to monitor and improve otherwise unregulated markets is expensive, ineffective, and impedes engagement. (3) The only meaningful adult life envisaged is paid work, despite a meagre and shrinking number of people with intellectual disabilities obtaining jobs. (4) The limitations of a legal inquiry are identified. (5) Alternatives to the promotion of voice, choice, and work are explored. Exhausted neoliberal ideology led the Commission astray. Rather than continuing to enact neoliberal solutions, two different initiatives that are more likely to disrupt the status quo are proposed: replacing legal intervention with public health approaches to reducing violence in all settings; and developing new “counter-publics” of fun and belonging that connect people and their consociates.

Variations in definitions used for describing restrictive care practices (seclusion and restraint) in adult mental health inpatient units: a systematic review and content analysis.

The main purpose of this review was to (1) identify thematic elements within definitions used by recently published literature to describe the constructs of physical/mechanical restraint, seclusion and chemical restraint in adult mental health inpatient units. We conducted a comprehensive literature search of six databases (Scopus, MEDLINE, PsycINFO, Web of Science, Embase, and CINAHL-Plus). In this review, we conducted content analysis to synthesize evidence to understand and compare the commonalities and discrepancies in conceptual elements that were incorporated within the definitions of different forms of restrictive care practices. A total of 95 studies that provided definitions for different forms of restrictive care practices [physical/mechanical restraint (n = 72), seclusion (n = 65) and chemical restraint (n = 19)] were included in this review. Significant variations existed in the conceptual domains presented within the applied definitions of physical/mechanical restraint, seclusion, and chemical restraint. Conceptual themes identified in this review were methods of restrictive care practice, reasons and desired outcomes, the extent of patient restriction during restrictive care practice episodes, timing (duration, frequency, and time of the day), the level of patient autonomy, and the personnel implementing these practices. Inconsistencies in the terminologies and conceptual boundaries used to describe the constructs of different forms of restrictive care practices underscore the need to move forward in endorsing consensus definitions that reflect the diverse perspectives, ensuring clarity and consistency in practice and research. This will assist in validly measuring and comparing the actual trends of restrictive care practice use across different healthcare institutions and jurisdictions.

Analisis Pembatasan Usia (Ageism) Pencari Kerja dalam Prespektif Hak Asasi Manusia (HAM)

The practice of ageism in the workplace is being discussed phenomenon. Age restrictions applied by the agency/company as the qualification of job seekers is assessed as discriminatory, unfair, detrimental, and not in line with the concept of human rights. This investigation aims to analyze the practice of age restrictions in human rights prospects. The research is carried out using a sociological jurisprudential method that emphasizes the facts found in the field. The results of the research show that the practice of age restrictions for job seekers assessed has limited the opportunities of the public to get a decent job and has been judged as an unobjective phenomenon. On the other hand, some countries in the world have abolished the practice of age restrictions, such as Germany, the Netherlands, and the United States.

What influences the use of seclusion? A cross-sectional study of forensic mental health nurses in a UK high secure hospital

PurposeIncidents of violence and aggression are a regular occurrence within adult forensic mental health inpatient settings and often lead to the use of restrictive practices such as seclusion. Such events are frequently attributed to the complexity of the patients. Research commonly focuses on patient’s characteristics and their association with seclusion use. Less attention has been centred on forensic mental health nurses’ attitudes to seclusion and the association of nursing staff characteristics.Design/methodology/approachA cross-sectional survey was undertaken using a standardised questionnaire, “Survey of Nurses’ Attitudes to Seclusion”. Responses were received from n = 147 nurses at a high secure forensic mental health hospital in the UK.FindingsKey findings indicate that most participants believed seclusion should remain part of clinical practice. A correlation was identified between forensic mental health nurses’ attitudes to seclusion use and their characteristics: gender, age range, educational level and experience.Practical implicationsThis paper presents novel information on seclusion reduction opportunities through modifiable workforce factors such as gender-sensitive rostering and staff training and development. Furthermore, recruitment and retention strategies should be prioritised so forensic mental health is perceived as an attractive career and a safe workplace.Originality/valueThe paucity of research in this area has prompted calls for further research to explore nursing staff characteristics and seclusion use. This is particularly important now due to the current global difficulty in the recruitment and retention of mental health nurses.

'Becoming restrained': Conceptualising restrictive practices in the care of people living with dementia in acute hospital settings.

The use of restrictive practices within health and social care has attracted policy and practice attention, predominantly focusing on children and young people with mental health conditions, learning disabilities and autism. However, despite growing appreciation of the need to improve care quality for people living with dementia (PLWD), the potentially routine use of restrictive practices in their care has received little attention. PLWD are at significant risk of experiencing restrictive practices during unscheduled acute hospital admissions. In everyday routine hospital care of PLWD, concerns about subtle and less visible forms of restrictive practices and their impacts remain. This article draws on Deleuze's concepts of 'assemblage' and 'event' to conceptualise restrictive practices as institutional, interconnection social and political attitudes and organisational cultural practices. We argue that this approach illuminates the diverse ways restrictive practices are used, legitimatised and perpetuated in the care of PLWD. We examine restrictive practices in acute care contexts, understanding their use requires examining the wider socio-political, organisational cultures and professional practice contexts in which clinical practices occurs. Whereas 'events' and 'assemblages' have predominantly been used to examine embodied entanglements in diverse health contexts, examining restrictive practices as a structural assemblage extends the application of this theoretical framework.

The impact of sensory modulation in acute mental health units: an organisational case study analysis

PurposeSensory modulation intervention involves using calming and grounding sensory stimuli to support coping with distress and intense emotions. Evaluating the impact of sensory modulation is challenging in inpatient settings due to the numerous variables influencing outcomes in ward environments. This study aims to determine the impact of sensory modulation across all organisational levels including service users, staff confidence and attitudes, ward climate and seclusion events.Design/methodology/approachOrganisational case studies were conducted in two Aotearoa New Zealand inpatient mental health services, using qualitative and quantitative data to explore the effects of a sensory modulation programme.FindingsResults showed that sensory modulation enhanced staff knowledge and confidence in fostering therapeutic relationships and reducing restrictive practices, positively impacted ward climate and provided service users with sensory strategies to use in everyday life.Practical implicationsThe findings captured the complexity of implementation and impact of sensory modulation programmes at individual, group and organisational levels. It is important to recognise the influencing factors and impact of sensory modulation across all levels of service delivery.Originality/valueOrganisational case study methodology offered a unique approach to evaluating the impact of sensory modulation within inpatient mental health services. Data analysis suggests that in addition to managing acute service user distress, sensory modulation impacts broader staff, team and service level outcomes.