Restraint Rates Research Articles

The Development and Implementation of Non-Violent Resistance in Child and Adolescent Residential Settings

ABSTRACT Non-violent Resistance (NVR) is a method to manage child and adolescent aggressive behavior and to decrease parental helplessness. Although developed for a family setting, this paper describes the adaptation of NVR for child and adolescent residential settings, reports on the possible hampering and facilitating elements of implementing NVR in four different institutions and finally presents seclusion and restraint rates before and after implementation. Retrospective analysis of the different implementation processes suggested the following elements to facilitate implementation: awareness that NVR is not a quick fix, a considerable amount of time and financial investment, a team-wide perspective, support from all levels in an organization and influential team members committed to NVR to decrease the risk of falling back into more familiar patterns. Seclusion and restraint figures pre-post point in the direction that the implementation of an adapted version of NVR in residential settings could result in decreased seclusion and restraint. Furthermore, this decrease was most pronounced in sites with a successful implementation process. This observational study provides a starting point for an empirical basis for the use of NVR within child and adolescent residential settings. Further research on successful implementation processes for multi-level, milieu-based interventions, such as NVR, is required.

The experiences of patients in using sensory rooms in psychiatric inpatient care.

The use of sensory rooms and similar sensory approaches in psychiatric inpatient settings is becoming increasingly common. In sensory rooms, patients can choose different sensory stimulating items that may help regulate distress and enhance well-being. Outcomes are often measured as effects on patients' self-rated distress and rates of seclusion and restraint. The subjective experiences of patients using sensory rooms have been less explored. This paper presents a qualitative study of the experiences of 28 patients who chose to use sensory rooms on seven different types of psychiatric inpatient wards. Data were collected by individual patient interviews and by texts written by patients. A qualitative content analysis resulted in four categories: emotional calm, bodily calm, empowerment, and unexpected effects. A majority of the participants described several positive experiences, such as enhanced well-being, reduced anxiety, increased self-management, and enhanced self-esteem. Our findings align with previous research that has shown similar positive patient experiences, and support the use of sensory rooms as part of person-centred care.

Minimising the use of physical restraint in acute mental health services: The outcome of a restraint reduction programme (‘REsTRAIN YOURSELF’)

BackgroundPhysical 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. ObjectiveAn 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. DesignA non-randomised controlled trial design was employed. SettingFourteen, 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. MethodAs 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). ResultsIn 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. ConclusionIn 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.

The Impact of Milieu Nurse-Client Shift Assignments on Monthly Restraint Rates on an Inpatient Child/Adolescent Psychiatric Unit.

INTRODUCTION: Restraints in the inpatient child/adolescent psychiatric population pose a threat to client safety and quality of care. Nurses are key in reducing restraints through implementation of evidenced-based interventions to improve quality and safety. AIM: To identify the impact of milieu nurse-client shift assignments on monthly restraint rates when compared with individual nurse-client shift assignments on an inpatient child/adolescent psychiatric unit. METHODS: A quantitative, retrospective, comparative project design was used. The sample included all inpatient child/adolescent clients admitted to the child/adolescent psychiatric unit between the months of January-May 2016 and 2017 who were physically or mechanically restrained. Retrospective chart audits were conducted, and information transcribed onto an adapted chart audit tool by Edwards et al. (2006). Monthly restraint rates were compared using the Mann-Whitney U test. A p value of <.05 was used to determine statistical significance. RESULTS: The Mann-Whitney U test revealed statistical significance between the impact that the individual nurse-client shift assignments (Mdn = 61.2, n = 6) and the milieu nurse-client shift assignments (Mdn = 6.8, n = 6) had on monthly restraint rates, U = .000, z = -2.88, p = .004, r = .83. CONCLUSION: Use of milieu nurse-client shift assignments are associated with lower monthly restraint rates when compared to individual nurse-client shift assignments. Milieu nurses provide structure, safety, consistency, and security, leading to early intervention and de-escalation of clients who display aggressive behaviors. Nurse staffing structures also need to be optimized to meet the needs of this population.

Methamphetamine use in patients presenting to emergency departments and psychiatric inpatient facilities: what are the service implications?

The aim of this study is to understand better the service implications of patients presenting to an inner city Australian Emergency Department (ED) and Acute Psychiatric Inpatient Service (AIS) with a history of recent crystal methamphetamine use. An audit was taken of all patients with recent crystal methamphetamine use presenting to St Vincent's Hospital Melbourne ED and AIS over the month of September 2017. Recorded information included patient demographics, diagnosis, aggressive episodes, restrictive interventions and other risk incidents. Methamphetamine was related to 21.7% of AIS admissions. Of these individuals, half were involved in aggression towards staff. In the ED, 65.7% of patients with amphetamine use were aggressive to staff and 50% were aggressive towards other patients. There were high rates of physical (69.2%) and mechanical restraint (61.5%) in the ED setting. Methamphetamine use in the AIS was commonly associated with enduring psychotic disorders, whilst those managed exclusively in the ED were most commonly in an acute intoxicated state. Methamphetamine use presents a significant challenge to EDs and acute mental health services. Additional resources are required to manage these patients and their impact on the health system needs to be factored into future service planning.

Reducing Use of Restraints in Intensive Care Units: A Quality Improvement Project.

Use of physical restrainst is scrutinized in intensive care units today. Usage rates for the 5 intensive care units in the Christiana Care Health Services, Newark, Delaware, were higher than the National Database of Nursing Quality Indicators mean rate of 9.61% to 15.43% for many months during fiscal years 2013 and 2014. To reduce and sustain the restraint rates to less than the national database mean rates for all 5 intensive care units. A quality improvement process was used that included forming a multiunit restraint collaborative; reviewing restraint data, including self-extubation rates; surveying staff nurses to examine alignment with evidence-based practice; and selecting a new restraint-alternative product. All 5 intensive care units were able to successfully decrease restraint rates to less than the national database mean for the majority of the months since the start of the restraint collaborative in September 2012. Use of a restraint collaborative with subsequent adoption of restraint alternatives led to a decrease in restraint rates for the 5 intensive care units to less than the national database mean, enabled sustained success, and helped align nurses' beliefs with evidence-based practice.

The effect of educational intervention on nurses' knowledge, attitude, intention, practice and incidence rate of physical restraint use.

The use of physical restraint exposes patients and staff to negative effects, including death. Therefore, teaching nursing staff to develop the improve knowledge, skills, and attitudes regarding physical restraint has become necessary. A quasi-experimental pre-post design was used to evaluate the effect of educational intervention on nurses' knowledge, attitude, intention, practice and incidence rate of physical restraint in 12 wards of a hospital using a self-reported questionnaire and a restraint order form in Malaysia. The educational intervention, which included a one-day session on minimising physical restraint use in hospital, was presented to 245 nurses. The results showed a significant increase in the mean knowledge, attitude sand practice score and a significant decrease in the mean intention score of nurses to use physical restraint after intervention. There was a statistically significant decrease in the incidence rate of physical restraint use in the wards of the hospital except geriatric-rehabilitation wards after intervention.

Restraint of adults with intellectual disabilities: A critical review of the prevalence and characteristics associated with its use.

As part of their care, adults with intellectual disabilities are often subject to restrictive interventions including restraint. A review examining the prevalence of restraint use with people with intellectual disabilities and the characteristics associated with its use. The seven papers identified used quantitative methodologies and had cross-sectional designs. Prevalence rates of restraint ranged from 11% to 78%, multiple forms of restraint were common. Most studies focused on characteristics within the person with an intellectual disability, three considered external factors. Challenging behaviour was the most consistent characteristic associated with the use of restraint, but how this was defined varied. The review highlights a need for more consistent means of defining and measuring restraint and its associated characteristics. Future research into this area may also want to focus on the context of restraint such as whether it is the least restrictive option used.

Implementation of Trauma-Informed Care and Brief Solution-Focused Therapy: A Quality Improvement Project Aimed at Increasing Engagement on an Inpatient Psychiatric Unit.

Addressing tense and escalating situations with noncoercive measures is an important element of inpatient psychiatric treatment. Although restraint rates are frequently monitored, the use of pro re nata (PRN) intramuscular (IM) injections to address agitation is also an important indicator. In 2015, at the current study site, a significant increase was noted in PRN IM medication use despite unit leadership's efforts to build a culture of trauma-informed care (TIC). The purpose of the current quality improvement project was to educate staff on methods to incorporate TIC into daily practice and the use of brief solution-focused therapy techniques in escalating situations. Measurement of attitudes toward patient aggression and engagement with patients followed two waves of staff education. Upon completion of the project, a decrease in PRN IM medications, improvement in staff attitudes toward patient aggression, and improved sense of staff competency in handling tense situations were noted. [Journal of Psychosocial Nursing and Mental Health Services, 56(8), 16-22.].

Factors Associated With Poor Child Motor Vehicle Restraint on the USA-Mexico Border.

Motor vehicle collisions (MVCs) are a significant cause of pediatric morbidity, particularly in low- to middle-income countries. We describe car seat use in children on the USA-Mexico border. A retrospective review was conducted for children 0-9 years old, admitted to the region's only Level I trauma center. Simultaneously, data were obtained from the SAFE KIDS database, a program that encourages car seat use through city checkpoints. There were 250 MVC admissions and nine fatalities in children 0-9 years old from 2010 to 2015. Nine percent of MVCs occurred in Mexico and 49% in El Paso, TX. Comparing trauma admissions to SAFE KIDS, there was some correlation between the location of MVCs and screening checkpoints (r = .50). There was a weaker correlation between injured children's neighborhoods and screening locations (r = .32). Only 37% of parents knew the crash history of the car seat and 3% were using a car seat previously involved in an MVC. While 96% of inspected children were placed appropriately in the backseat, 80% of children were found to be inappropriately restrained. Younger children more likely to be restrained (p < .05). Children from New Mexico and Mexico had the lowest rates of proper restraint and the highest injury severity scores. Proper use of car seats is a public health concern on the USA-Mexico border, and children are not properly restrained. Screening may be improved by focusing where at-risk children live and where most accidents occur. Restraint education is needed, particularly in New Mexico and Mexico.

Physical restraints: An ethical dilemma in mental health services in China

Given that physical restraints cause adverse effects to patients and nurses, their wide and frequent use has resulted in various clinical and ethical controversies in mental health services. The rate of physical restraints is significantly higher in China than in other countries. Some western and domestic media blamed relevant institutions for compromising the basic rights of psychiatric patients. Therefore, this study aims to collect and synthesize the relevant ethical evidence and to provide corresponding guidance for the nursing practice based on the current situation of the mainland of China. This study synthesized the ethical issue according to the ethical principle of autonomy, justice, beneficence, and non-maleficence. Given the current situation where the nursing workforce is limited and the mental health service is under-developed in China, applying physical restraints in the psychiatric inpatients to guarantee the safety of patients and nurses is crucial. In regard to respect the basic rights of psychiatric patients, it is recommended to protect the their autonomy, and eliminate the adverse effects of physical restraint. This goal would be achieved by ensuring the informed consent, providing humane care, and regulating the implementation of physical restraints.

Sensory Reduction on the General Milieu of a High-Acuity Inpatient Psychiatric Unit to Prevent Use of Physical Restraints: A Successful Open Quality Improvement Trial.

Impaired sensory gating in patients with acute mental illness predisposes to overstimulation and behavioral dyscontrol. Explore use of sensory reduction interventions on a high-acuity inpatient milieu to reduce high assault/restraint rates. A multidisciplinary team using failure mode and effect analysis to explore high restraint use between 4:00 p.m. and 7:00 p.m. observed patient/staff overstimulation contributed to behavioral escalations. The team implemented sensory reduction/integration improvements over a 5-month period to prevent excessive restraint use. Restraint rates dropped immediately following light and sound reduction interventions and by 72% at 11 months postimplementation. Mann-Whitney statistics for unpaired 6-month comparisons, 1-year pre- and postintervention showed significant reductions: Assault rates (median pre = 1.37, post = 0.18, U = 4, p = .02); Restraint rates (median pre = 0.50, post = 0.06, U = 0, p = .002). Sensory reduction during a high-stress time period on a high-acuity psychiatric unit was associated with a reduction in assaults and restraints.

The Introduction of Emotion Coaching as a Whole School Approach in a Primary Specialist Social Emotional and Mental Health Setting: Positive Outcomes for All

Background:This paper describes the impact upon well-being of pupils, staff, and families following the introduction of Emotion Coaching as a whole school approach.Objective:This paper’s objective is an attempt to redress the lack of published evidence about the use of Emotion Coaching in schools and to highlight how a school has been able to adopt a humanistic relational approach in a climate in which behaviorist principles are dominant in schools.Method:A case study approach using mixed methods was used. Data were examined from an outcomes model perspective where the benefits and changes intended from Emotion Coaching were the starting point. Perspectives from pupils, staff, and families were gainedviainterviews and structured questionnaires alongside quantitative measures of pupil academic progress and staff and pupil behavior.Results:Results indicate that Emotion Coaching improved the pupil’s ability to regulate their feelings and had a positive effect upon teacher-pupil relationships. Family-school relationships were supported by the school’s use of and modeling of Emotion Coaching with families and the ethos of attunement and non-judgemental interactions implicit in Emotion Coaching. Emotion Coaching promoted an increase in shared emotional language and trust. Shared emotional language and trust were key in the development of both teacher-pupil and family-school relationships. There was an improvement in well-being in that: rates of pupil restraint decreased, pupils made better than expected academic progress, staff absenteeism reduced, and families reported improved family life.Conclusion:We conclude that Emotion Coaching contributes to the promotion of sustainable, holistic improvement in wellbeing for pupils, school staff, and families.

Applying sensory modulation to mental health inpatient care to reduce seclusion and restraint: a case control study

Background: Clinical training in managing conflicts and preventing violence seldom contains sensory modulation (SM) as a method to de-escalate and prevent restraint and seclusion. Sensory-based interventions promote adaptive regulation of arousal and emotion. SM is a complementary approach that is associated with reduced rates of seclusion and restraint in mental healthcare, but there is need for more research in this area.Aims: Using SM to reduce restraint and seclusion in inpatient mental health care.Methods: The study included two similar psychiatric units where one unit implemented SM and one unit served as the control group. In the very beginning of the study, a staff-training program in the use of SM including assessment tools and intervention strategies was established. Data on restraint and forced medicine were sampled post the course of the year of implementation and compared with the control group.Results: The use of belts decreased with 38% compared to the control group. The use of forced medication decreased with 46% compared to the control group. Altogether the use of physical restraint and forced medication decreased significantly with 42% (p < .05).Conclusions: Implementing a SM approach in mental healthcare facilities has a significant effect on the reduction of restraint and seclusion. As a part of the implementation, staff training and education in SM are crucial.

Application of project management to reduce the effects of physical restraint for psychiatric inpatients

Objective To explore the effects of project management to reduce the rate of physical restraint for psychiatric inpatients. Methods From October 2014 to December 2015, 160 nurses was selected for the study in the hospital by whole group sampling method. Through the perfect system, processes and guide construction for physical restraint, as well as more training, implement and supervision, we observed the rate, duration and frequency of physical restraint, the achieved rate of physical restraint nursing quality and the adverse event incidences before (October to December in 2014) and after (October to December in 2015) project management. Results After the project management, the restraint rate was 53.42%, the duration of restraint (4.07±0.50) h, and the restraint's times for patients (2.35±1.25) , which were all lower than that before the intervention (P 0.05) . Conclusions Project management not only provides advanced management methods for nurse administrators, but also reduces the rate of physical restraint for psychiatric inpatients, and improves the quality of physical restraint nursing. Key words: Mental disorder; Project management; Hospitalization; Rate of physical restraint; Nursing quality

U.S. Child Safety Seat Laws: Are they Effective, and Who Complies?

This paper assesses the effectiveness of child safety seat laws in the United States. Over the past 35 years, these laws have steadily increased mandatory child safety seat restraint ages. We exploit state-year level variation in the age until which children are required to ride in child safety seats to estimate triple difference models using Fatality Analysis Reporting System (FARS) data from 1975 to 2011. Our findings show that increasing the age thresholds is effective in increasing the actual age of children in safety seats. Across the child-age distribution, restraint rates increase by between 10 and 30 percentage points or by between 50 and 170 percent, in the long run. We also estimate the impact of the child safety seat laws on the likelihood that a child dies in a fatal accident. We find that the laws saved up to 39 children per year. Finally, we find that the laws primarily induce compliant parents to switch from traditional seatbelt use to child safety seat use, with only small effects among parents who do not restrain their children.

Reducing restraint with clozapine in involuntarily admitted patients with schizophrenia

IntroductionIn the entire world, restraint and seclusion are common interventions in psychiatric in-patient settings due to aggressive behavior.ObjectivesOur objective was to test for the immediate anti-aggressive property of clozapine compared to other antipsychotic treatments in an enriched cohort with high rates of restraint during early hospitalization.MethodsWe present a retrospective chart review in all involuntary admissions with schizophrenia during 2011–2014 in Psychiatry and Neurology Hospital, Brasov, Romania. Timing and number of restraints in addition to clinical, demographic and treatment characteristics were extracted. Based on our earlier observation of clinical efficacy of early, fast titration of clozapine, we tested the hypothesis that clozapine treatment was associated with reduced use of restraint, and with longer restraint-free periods.ResultsIn 115 patients with schizophrenia (age = 39.7 ± 11.1 years; male = 59%) involuntarily admitted due to externalized (74.78%) or self-directed violence (25.22%), restraint was used in 89.6%; with a median duration of 3 hours until restraint past admission. Antipsychotics used immediately after hospitalization included haloperidol (70.4%), clozapine (11.3%), olanzapine (10.4%) and other second-generation antipsychotics (7.9%). Comparison of restraint characteristics favored immediate clozapine use with highly reduced rates of restraint (38.5% vs.95.6%. P &lt; 0.001) and significantly extended hours until restraint ([118 h,24 h, 426 h] vs.[3 h,0.25 h, 48 h]; median; 25th, 75th percentile; P &lt; 0.001) relative to the remaining cohort. These effects remained highly significant after controlling for potential moderators of restraint use in multivariate models.ConclusionsThese retrospective data suggest an early anti-aggressive effect of clozapine during the immediate use of clozapine in highly problematic patients.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Elevated C-reactive protein levels associated with aggressive behavior in Moroccan patients with schizophrenia

BackgroundRecent studies reported an association between aggression and inflammation. In this study, we examined the association between aggressive behavior and inflammatory markers (serum levels of CRP) in schizophrenia inpatients.MethodsAdult schizophrenia inpatients (n = 145) were prospectively identified and categorized according to their C-reactive protein measurement at admission as either elevated (CRP &gt; 1 mg/dL; n = 45) or normal (CRP &lt; 1 mg/dL; n = 100). The following indicators of aggression were compared: PANSS excitement component (PANSS-EC), restraints and suicidal behavior during hospitalization.ResultsThe results show that patients with elevated CRP levels are more aggressive during hospitalization as detected by statistically significant higher scores of aggressive behavior (PANSS-EC score), and by increased rates of physical restraint during hospitalization. No statistically significant differences in the other clinical features, including suicidal behavior.ConclusionOur results are consistent with previous findings linking schizophrenia to activation of the inflammatory response system.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Reducing Restraint With Clozapine in Involuntarily Admitted Patients With Schizophrenia.

In the entire world, restraint and seclusion are common interventions in psychiatric inpatient settings because of aggressive behavior. Our objective was to test for the immediate antiaggressive property of clozapine compared with other antipsychotic treatments in an enriched cohort with high rates of restraint during early hospitalization. We present a retrospective chart review in all involuntary admissions with schizophrenia during 2011-2014 in Psychiatry and Neurology Hospital, Brasov, Romania. Timing and number of restraints in addition to clinical, demographic, and treatment characteristics were extracted. Based on our earlier observation of clinical efficacy of early, fast titration of clozapine, we tested the hypothesis that clozapine treatment was associated with reduced use of restraint and with longer restraint-free periods. In 115 consecutive patients with schizophrenia (age = 39.7 ± 11.1 years; male = 59%) involuntarily admitted because of externalized (74.7%) or self-directed violence (25.2%), restraint was used in 89.6%; with a median duration of 3 hours until restraint past admission. Antipsychotics used immediately after hospitalization included haloperidol (70.4%), clozapine (11.3%), olanzapine (10.4%), and other second-generation antipsychotics (7.9%). Comparison of restraint characteristics favored immediate clozapine use with highly reduced rates of restraint (23% vs. 95.6%; P < 0.001) and significantly extended hours until restraint [(118, 24, 426 hours) vs. (3, 0.25, 48 hours); median; 25th, 75th percentile; P < 0.001] relative to the remaining cohort. These effects remained highly significant after controlling for potential moderators of restraint use in multivariate models. These retrospective data suggest an early antiaggressive effect of clozapine during the immediate use of clozapine in highly problematic patients.

Influence of Uplift Load on Torsional Restraint Provided to Steel Thin-Walled Purlins by Sandwich Panels

The sandwich panels have been widely used as members of roof and wall cladding. In addition to their primary function, they can provide lateral and torsional restraints to the supporting members and therefore contribute to their buckling resistance. The availability of the provided restraints is influenced by the direction of the load applied to the surfaces of the panels. For the uplift load, no torsional restraint is conservatively considered due to reduction of the contact area between the panels and the supporting metal members. Possible small rate of the torsional restraint should be verified by experimental investigation.The paper focuses on the experimental verification of the torsional restraint provided to steel purlins of thin-walled cold-formed cross-sections by adjacent sandwich panels. For the first series of tests a simple test set-up with no external load applied to the surface of the panel was utilized. The second series comprises tests of the torsional restraint provided to steel purlins by sandwich panels under uplift load. A complex test set-up taking into account the external load applied to the surfaces of the panels was used. The results of both test approaches are compared and the influence of the uplift load on the torsional restraint for the tested specimens is evaluated.