Use Of Restraints Research Articles

Safer Behind Bars? Comparing In-Custody Deaths Prior to and During Incarceration

IntroductionThis project aims to characterize trauma-associated deaths of the American incarcerated population through legal intervention (LI) or death by law enforcement officials while in custody before and during incarceration. We determined the preceding events leading to violent death, including initiation of medical care, use of restraints and force, and demographics of the victims. MethodsWe used National Violent Death Reporting System data from the years 2003-2019 to identify deaths that occurred while in custody or incarcerated, including discriminate and narrative data. Event information included weapon type, location of death, incident type, incarceration status, use of restraints, and prone positioning. ResultsThere were 86 victims who died from LI included in the analysis. Most events occurred after incarceration. All victims in our cohort were male, and race was an associated factor for death by LI. Only 16% of victims had an education level above high school/general educational development. Death by firearm compared to other weapons was significantly more common in the in-custody but not yet incarcerated group (83% versus 42%, P ≤ 0.0001). Other associated factors included a history of mental health, physical confrontations, the belief that the victim had a weapon, and being restrained in prone positioning. ConclusionsOur study shows that racial minority victims are disproportionately affected by LI deaths. Firearms and restraint type were important factors in LI deaths. Our findings suggest that violence prevention in the justice system should focus on prevention and de-escalation across setting with specific attention to use of force and inmate access to the weapons of police, guards, and other law and justice system workers. More transparent quality data is sorely needed to adequately define and address this problem.

Chemical restraint as behavioural euthanasia: case studies from the Royal Commission into Aged Care Quality and Safety

BackgroundThe prescription of psychotropic medication to older people living with dementia in residential aged care has become an increasing concern. The use of prescription medication is often prefaced as a way of preventing harm to self and others. However, the use of such medications has been considered a way of managing some of the behavioural and psychological symptoms of dementia. Using a large secondary data set, this study aimed to identify the precursors and mediating factors that influence the use of chemical restraint of older people in residential aged care.MethodsPublicly available documents from the Australian Royal Commission into Aged Care Quality and Safety were used as the data corpus for this study. Keywords were used to search over 7000 documents to extract a set of topic-related content. We identified the cases of seven people in respite or permanent residential aged care who had been prescribed or administered psychotropic medication under circumstances that appeared to demonstrate chemical restraint. All documents relating to the cases were collated for our data set. A descriptive case study approach to analysis was taken.ResultsFour key descriptive patterns were identified: labelling and limits to tolerance, pushing prescription as a solution, coverups and avoiding consent, and family’s fight for liberty. Triangulation across the data and academic literature supports the findings.ConclusionOur findings provide some insight into how chemical restrain happens. Featuring throughout the cases were reports of a lack of workforce capacity to care for and support residents exhibiting dementia behaviours. Prescription of psychotropic medications featured as a “first resort” care solution. Family and friends found such approaches to care unacceptable and frequently challenged the practice. Where consent for prescription was explicitly denied, more covert approaches are demonstrated. Family awareness, presence, and advocacy were key to challenging the practice of chemical restraint. Shortfalls in the capacity of the current workforce come into play here. However, workforce shortcomings can no longer mask this ubiquitous practice. Just as importantly the spotlight needs to be turned on the prescribers and the providers.

Differences in participant characteristics and observed child restraint use between population-based and restraint fitting service samples

Objective To compare characteristics and restraint use between a population-based and fitting service sample of child restraint users. Method Characteristics of the two samples were compared using chi-squared tests. Differences in errors in restraint use observed in the two samples were modeled using logistic regression. Results There were significant differences in child age (p < 0.001), and restraint types (p < 0.001) between the two samples, with more younger children in the fitting service sample. Controlling for differences in restraint type, the odds that adult participants were female were 61% less in the fitting service sample than in the population-based sample (OR 0.39, 95%CI 0.21–0.71). The odds that adult participants perceived a large risk associated with restraint misuse (OR 3.62, 95%CI 1.33–9.84), had a household income in the highest bracket (OR 3.89, 95%CI 1.20–12.62) and were living in areas of highest socioeconomic advantage (OR 2.72, 95%CI 1.22–6.06) were approximately three times higher in the fitting service sample. Overall, more participants had errors in restraint use in the population-based sample (p = 0.021). However, after controlling for restraint type, securing errors were three times more likely (OR 3.34, 95%CI 1.12–10.2), and serious installation errors were almost twice as likely (OR 1.91, 95% CI 1.09–3.39) in the fitting service sample. Conclusions While less resource intensive, convenience and/or fitting service samples may be less representative than population-based samples. Given the need for efficiency, methods that combine randomized population-based invitations to participate in restraint fitting check day events across geographically representative areas may be useful for ongoing surveillance of child restraint use.

'You have to be a certain sort of person': An interpretative phenomenological analysis of mental health support workers' experiences of physical restraint in inpatient settings.

Physical restraint is a controversial practice in psychiatric inpatient settings. Research has clearly demonstrated its physical and psychological risks, but few studies investigate how mental health support workers understand their experiences of restraint use. This study uses interpretative phenomenological analysis to explore support workers' understanding of these experiences. The COREQ checklist was used to ensure explicit reporting of the study. Semi-structured interviews were conducted with three participants and were then analysed using an interpretative phenomenological process. One superordinate theme emerged: 'You have to be a certain sort of person'. Restraints require not only the ability to overcome one's emotions, but also the ability to connect with the person being restrained. The implications of these findings for psychiatric care provision and for further research are discussed.

Toward the Cessation of Seclusion and Mechanical Restraint Use in Psychiatric Hospitals: A Call for Regulatory Action.

The use of seclusion and mechanical restraints (S-R) in psychiatric hospitals remains widespread despite the traumatizing effects and risk for lethality associated with these practices. Neither the Centers for Medicare and Medicaid Services (CMS) nor The Joint Commission (TJC) have updated their guidelines on the use of S-R since 2005. Their regulations do not include current best practices, such as the evidence-based six core strategies (6CS) or other trauma-informed approaches, despite robust data on their effectiveness in preventing violence and S-R use. The authors describe Pennsylvania State hospitals' nearly 10-year cessation of S-R use via their continuous adherence to 6CS. In contrast, the authors describe the significant decrease in S-R use during the implementation of 6CS at a public psychiatric hospital while under U.S. Department of Justice (DOJ) monitoring and the resumption of high S-R use after DOJ monitoring and adherence to 6CS ended. The authors emphasize the importance of external regulatory oversight and mandates to safely achieve and sustain the cessation of S-R use in psychiatric hospitals. Urging CMS and TJC to update their regulations, the authors offer a roadmap to more effectively mandate the reduction and eventual cessation of S-R use in psychiatric hospitals.

Characterizing Racial Disparities in Emergency Department Pediatric Physical Restraint by Sex and Age

This cross-sectional study evaluates racial disparities in physical restraint use in US emergency departments.

Implementation of a case formulation to reduce restrictive interventions on a psychiatric intensive care unit: quasi-experimental single case evaluation.

Despite the use of case formulation being encouraged for in-patient psychiatric care, there have been no previous examples and evaluations of this type of work on a psychiatric intensive care unit (PICU). To evaluate whether a schema-informed formulation with a patient diagnosed with emotionally unstable personality disorder (EUPD), autism spectrum disorder (ASD) and mild learning difficulties was effective in reducing the use of restrictive interventions. A biphasic n = 1 quasi-experimental design with an 8-week baseline versus an 8-week intervention phase. The restrictive outcomes measured were use of physical restraint, seclusion, and intramuscular rapid tranquilisation. The formulation was developed through eight one-to-one sessions during the baseline period, and was implemented via six one-to-one sessions during the intervention phase and discussion at the ward reflective practice group. The intervention encouraged better communication of schema modes from the patient and for staff to then respond with bespoke mode support. Incidents involving need for seclusion, restraint and rapid tranquilisation extinguished. The need for making access to psychological input a routine aspect of the care in PICUs and the necessity for developing a methodologically more robust evidence base for psychological interventions on these wards.

Comparing quality of care outcomes between assisted living and nursing homes before and during the COVID-19 pandemic.

While assisted living (AL) and nursing home (NHs) residents in share vulnerabilities, AL provides fewer staffing resources and services. Research has largely neglected AL, especially during the COVID-19 pandemic. Our study compared trends of practice-sensitive, risk-adjusted quality indicators between AL and NHs, and changes in these trends after the start of the pandemic. This repeated cross-sectional study used population-based resident data in Alberta, Canada. Using Resident Assessment Instrument data (01/2017-12/2021), we created quarterly cohorts, using each resident's latest assessment in each quarter. We applied validated inclusion/exclusion criteria and risk-adjustments to create nine quality indicators and their 95% confidence intervals (CIs): potentially inappropriate antipsychotic use, pain, depressive symptoms, total dependency in late-loss activities of daily living, physical restraint use, pressure ulcers, delirium, weight loss, urinary tract infections. Run charts compared quality indicators between AL and NHs over time and segmented regressions assessed whether these trends changed after the start of the pandemic. Quarterly samples included 2015-2710 AL residents and 12,881-13,807 NH residents. Antipsychotic use (21%-26%), pain (20%-24%), and depressive symptoms (17%-25%) were most common in AL. In NHs, they were physical dependency (33%-36%), depressive symptoms (26%-32%), and antipsychotic use (17%-22%). Antipsychotic use and pain were consistently higher in AL. Depressive symptoms, physical dependency, physical restraint use, delirium, weight loss were consistently lower in AL. The most notable segmented regression findings were an increase in antipsychotic use during the pandemic in both settings (AL: change in slope = 0.6% [95% CI: 0.1%-1.0%], p = 0.0140; NHs: change in slope = 0.4% [95% CI: 0.3%-0.5%], p < 0.0001), and an increase in physical dependency in AL only (change in slope = 0.5% [95% CI: 0.1%-0.8%], p = 0.0222). QIs differed significantly between AL and NHs before and during the pandemic. Any changes implemented to address deficiencies in either setting need to account for these differences and require monitoring to assess their impact.

Prevalence and risk factors of the use of physical restraint and impact of a decision support tool: A before-and-after study.

Physical restraint is frequently used in intensive care units to prevent patients' life-threatening removal of indwelling devices. In France, their use is poorly studied. Therefore, to evaluate the need for physical restraint, we have designed and implemented a decision support tool. Besides describing the prevalence of physical restraint use, this study aimed to assess whether the implementation of a nursing decision support tool had an impact on restraint use and to identify the factors associated with this use. A large observational, multicentre study with a repeated one-day point prevalence design was conducted. All adult patients hospitalized in intensive care units were eligible for this study. Two study periods were planned: before (control period) and after (intervention period) the deployment of the decision support tool and staff training. A multilevel model was performed to consider the centre effect. During the control period, 786 patients were included, and 510 were in the intervention period. The prevalence of physical restraint was 28% (95% CI: 25.1%-31.4%) and 25% (95% CI: 21.5%-29.1%) respectively (χ2 = 1.35; p = .24). Restraint was applied by the nurse and/or nurse assistant in 96% of cases in both periods, mainly to wrists (89% vs. 83%, p = .14). The patient-to-nurse ratio was significantly lower in the intervention period (1:3.0 ± 1 vs. 1:2.7 ± 0.7, p < .001). In multivariable analysis, mechanical ventilation was associated with physical restraint (aOR [95% CI] = 6.0 [3.5-10.2]). The prevalence of physical restraint use in France was lower than expected. In our study, the decision support tool did not substantially impact physical restraint use. Hence, the decision support tool would deserve to be assessed in a randomized controlled trial. The decision to physically restrain a patient could be protocolised and managed by critical care nurses. A regular evaluation of the level of sedation could allow the most deeply sedated patients to be exempted from physical restraint.

Factors influencing agitation, de-escalation, and physical restraint at a children's hospital.

Children hospitalized in medical hospitals are at risk of agitation. Physical restraint may be used to maintain patient and staff safety during de-escalation, but physical restraint use is associated with physical and psychological adverse events. We sought to better understand which work system factors help clinicians prevent patient agitation, improve de-escalation, and avoid physical restraint. We used directed content analysis to extend the Systems Engineering Initiative for Patient Safety model to clinicians working with children at risk for agitation at a freestanding children's hospital. We conducted semistructured interviews to examine how five clinician work system factors affected patient agitation, de-escalation, and restraint: person, environment, tasks, technology and tools, and organization. Interviews were recorded, transcribed, and analyzed until saturation. Forty clinicians participated in this study, including 21 nurses, 15 psychiatric technicians, 2 pediatric physicians, 1 psychologist, and 1 behavior analyst. Work system factors that contributed to patient agitation were medical tasks like vital signs and the hospital environment including bright lights and neighboring patients' noises. Supports that helped clinicians de-escalate patients included adequate staffing and accessible toys and activities. Participants indicated that organizational factors were integral to team de-escalation, drawing connections between units' teamwork and communication cultures and their likelihood of successful de-escalation without the use of physical restraint. Clinicians perceived that medical tasks, hospital environmental factors, clinician attributes, and team communication influenced patients' agitation, de-escalation, and physical restraint. These work system factors provide opportunities for future multi-disciplinary interventions to reduce physical restraint use.

Attitudes about Mechanical Restraint Use in Mental Health Hospitalization Services: A Spanish Survey.

The aim of this study was to analyze the attitudes of professionals in Mental Health Services throughout Spain who are directly or indirectly involved in the use of mechanical restraint and the barriers perceived to reduce its use. The study involved an online anonymous survey using Google Forms completed by Spanish mental health professionals working with service users; the survey assessed their involvement in and general attitudes and beliefs towards mechanical restraint. The survey was completed by 225 participants. Only 13.30% of the participants considered that mechanical restraint use was never necessary to guarantee the safety of users/staff in dangerous situations. Poor staff training (38.0%) and a lack of resources/staff (34.7%) were the most frequent barriers identified for the reduction of mechanical restraint. In the multivariate analysis, participation in learning programs to prevent the use of mechanical restraint was associated with lower acceptance of the use of mechanical restraint, but the result was barely significant (p = 0.050). A high percentage of mental health staff still consider mechanical restraint use necessary for safety reasons. According to the results, the participants perceived that more staff and resources and better training could reduce the use of mechanical restraint in Mental Health Hospitalization Services.

Discussing physical restrictions in care plan meetings between family members of residents with dementia and nursing home staff.

In long-term dementia care, caregivers face a dilemma. On the one hand, they need to respect the residents' right to self-determination, but on the other hand, they sometimes rely on physical restraints to deal with potential violence and self-destructive behavior. The issue of self determination is further complicated by residents often depending on family members as advocates in decision-making. In this article, we examine 15 care plan meetings to identify the professional practices of discussing the physical restrictions posed to residents with severe dementia. Our method is conversation analysis. Our analysis demonstrates that staff members' practices involve informing, accounting, and agreeing on the goals rather than on the methods of physical restraining. Staff members tend to first inform family members about the principles of restraining and then account for the use of restraints. Accounts highlight the problems that can be avoided and the benefits that can be achieved by limiting residents' actions. Consequently, the family members' role in the discussion is to accept the decision that has already been approved by authorities. As the staff members highlight the aim of protecting the well-being of the resident, the family members tend to respond with overt agreement and even promote the use of restraints. Current negotiation practices provide insufficient opportunities for family members to advocate for residents. Therefore, we recommend involving family members in decision-making about restraining at an earlier stage, adjusting the protocol in care plan meetings, and engaging the family in minimizing and preventing restraints. In general, staff members should pay more attention to the residents' experiences and the family members' lifeworld knowledge of the residents.

요양보호사에 의한 노인의 신체억제 경험에 영향을 미치는 요인

Since the National Long-Term Care Insurance of 2008, licensed caregivers for older adults have dramatically increased in Korea. In contrast to such trends, their care capacity has been socially concerned about violation against human rights such as elder abuse including physical restraints. The distinction between physical restraints and physical abuse is ambiguous at care settings which has brought in hot debate on the violation of human rights. Therefore, we investigated the extent to which caregivers’awareness of physical restraints and reasons of elder abuse and their witness of physical restraints are associated with their physical restraints on older adults. We used the secondary data collected from 3,859 licensed caregivers working at about 3,000 day care centers across the nation in 2017. First, we found that 10.7% of caregivers performed restrictive interventions. Second, the awareness of physical restraints, witness of others’physical restraints, and their own physical restraints are related to each other. Lastly, logistic regressions confirmed that caregivers’poor awareness of physical restraints, more witness of physical restraints by other caregivers, and higher perception of victim’s personality problems mainly causing elder abuse were more likely to increase their use of physical restraints. These findings suggest that care environment insensitive to human rights might lead to elder abuse by over-utilizing physical restraints. Also, it is fundamental to develop professional care culture of licensed caregivers towards person-centered care.

형사사법에서의 인공지능 예측프로그램 활용 제언

In recent period, crime prediction programs have been newly introduced and utilized internationally in the field of criminal justice. COMPAS (“Corrective Offender Management Profiling for Alternative Sanctions”), as a representative example, is a recidivism prediction program used in several States in the United States. COMPAS is the most widely used risk assessment tools in the United States. The U.S. company Northpointe has developed an artificial intelligence algorithm that predicts the possibility of recidivism by analyzing the accumulated data such as criminal records, family relationships, educational history, drug abuse, etc. However, as it has been controversially argued that the results of these algorithms violate the defendants' constitutional rights, fundamental questions arise on how the results of the algorithm are produced, and what factors are calculated in judging a specific decision. In the era of A.I., ‘artificial intelligence’ is a concept that encompasses both technology development, utilization, and operation systems, normative judgment and policy design related to the use of the system in the judicial system. Furthermore, ethical guidelines for preventing individual risks in the use of artificial intelligence and other legal restraints, including criminal sanctions, should be established. Based on the crime prediction, this study will discuss the bias and racism of algorithms based on crime prediction technologies. This paper further aims to scrutinize the crime prediction and artificial intelligence algorithms in relation to the racial discrimination and social inequality against specific groups in criminal justice. Though not as much as in the U.S., often referred to as a ‘salad bowl’ society, South Korea has also entered a multicultural society due to recent surge in immigration, labor market, and international marriage. Lastly, the author emphasizes the importance of further research on the utilization of crime prediction tool in South Korea, as it requires careful deliberation and thorough comparative legal research prior the adoption of the new technology in the criminal justice system.

Updates to American Psychiatric Nurses Association: Seclusion and Restraint Position Statement and Standards of Practice.

The purpose of this discussion paper is to summarize the 2022 updates to the American Psychiatric Nurses Association's (APNA) Seclusion and Restraint Position Statement and Seclusion and Restraint Standards of Practice. Both documents were the work of the APNA 2022 Seclusion and Restraint Task Force that consisted of APNA nurses with expertise in the use of Seclusion and Restraint, who practice across a wide range of clinical settings. The 2022 Updates to the APNA Position Statement and Standards were guided by evidence-based information found in the review of seclusion and restraint literature and clinical expertise from the 2022 Seclusion and Restraint Task Force. Updates were evidence-based and in line with APNA's core values and initiatives in diversity, equity, and inclusion.

Pregnant Prisoners in Shackles

Pregnant Prisoners in Shackles

Reduction of adverse events in a psychiatric inpatient eating disorder unit during the COVID-19 pandemic.

Globally, the COVID-19 pandemic had impacted the health care delivery including inpatient psychiatric facilities. Within psychiatric settings, life of inpatients was profoundly altered. This paper aimed to understand if pandemic-related changes within an inpatient Eating Disorder Unit in a specialized psychiatric hospital in Ontario, Canada impacted incidence of aggression and use of coercive methods among adolescents. An exploratory study design was used to examine incidence of aggression, self-harm, code whites, staff assist, restraints and seclusion, and nasogastric feeding (NGF) among adolescents with eating disorders before and after the modified service delivery within the inpatient unit. Descriptive analyses were conducted. Analyses revealed a complete reduction in episodes of self-harm, aggression, staff assists, use of restraint and seclusion as well as an 80.14% reduction on average use of NGF. Authors speculate that the change in environment and program delivery method, peer influence, and shift in power relations between patient and staff may have resulted in improved experiences. This report provides insights to adopt a recovery-oriented service delivery for adolescents with eating disorders in inpatient settings.

"It's not a nice thing to do, but…": A phenomenological study of manual physical restraint within inpatient adolescent mental health care.

To explore nursing staff's experiences of using manual (physical) restraint within inpatient adolescent mental health care. This was a descriptive phenomenological study. Individual semi-structured interviews were conducted with 12 nursing staff between March 2021 and July 2021. The nursing staff were recruited from four inpatient adolescent mental health hospitals across three National Health Service Trusts in England. Interviews were transcribed verbatim and analysed using Braun and Clarke's reflexive approach to thematic analysis. Four themes were generated from the analysis: (1) it needs to be done sometimes; (2) it's not a nice thing to do; (3) it does not really damage the therapeutic relationship; and (4) importance of team support. Despite strongly reporting that it was sometimes necessary to manually restrain young people for substantial safety reasons, participants spoke with dislike about its use, and described consequential aversive experiences of emotional distress, patient aggression, pain and injury, and physical exhaustion. Participants reported relying on each other for emotional and practical support. Three participants reported observing premature restraint use by non-permanent staff. The findings detail a paradoxical picture of the nursing staff's experiences where restraint is experienced as psychologically and physically aversive yet deemed as sometimes necessary to prevent significant harm. The Standards for Reporting Qualitative Research (SRQR) checklist was used to guide reporting. This study suggests a need for the targeting of non-permanent staff for restraint minimization interventions, and highlights how the treatment of non-permanent staff by permanent staff may contribute to avoidable restraint practices. The findings indicate several ways in which the staff-young person therapeutic relationship can be preserved in the context of restraint. However, this needs to be treated with caution given that young people's voices were missing from this study. This study focused on nursing staff's experiences.

Patient-centered inpatient psychiatry is associated with outcomes, ownership, and national quality measures.

Following discharge from inpatient psychiatry, patients experience elevated suicide risk, unplanned readmission, and lack of outpatient follow-up visits. These negative outcomes might relate to patient-centered care (PCC) experiences while hospitalized. We surveyed 739 former patients of inpatient psychiatric settings to understand the relationship between PCC and changes in patients' trust, willingness to engage in care, and self-reported 30-day follow-up visits. We also linked PCC measures to facility-level quality measures in the Inpatient Psychiatric Facility Quality Reporting program. Relative to patients discharged from facilities in the top quartile of PCC, those discharged from facilities in the bottom quartile were more likely to experience reduced trust (predicted probability [PP] = 0.77 vs 0.46; P < .001), reduced willingness to go to the hospital voluntarily (PP = 0.99 vs 0.01; P < .001), and a lower likelihood of a 30-day follow-up (PP = 0.71 vs 0.92; P < .001). PCC was lower among patients discharged from for-profits, was positively associated with facility-level quality measures of 7- and 30-day follow-up and medication continuation, and was inversely associated with restraint use. Findings underscore the need to introduce systematic measurement and improvement of PCC in this setting.

Treatment of pediatric behavioral health patients with intravenous and intramuscular chemical restraints: Results from a nationwide sample of emergency departments.

Behavioral health crises in pediatric emergency department (ED) patients are increasingly common. Chemical restraints can be utilized for patients who present imminent danger to self or others. We sought to describe the use of intravenous (IV)/intramuscular (IM) chemical restraints for pediatric behavioral health ED patients across a nationwide sample of hospitals and describe factors associated with restraint use. This was a retrospective study of patients ages 8-17 treated at 822 EDs contributing data to the Premier Healthcare Database between January 1, 2018, and December 31, 2020, with a behavioral health discharge diagnosis. The primary outcome was the use of IV/IM chemical restraint medication. We developed a hierarchical model to examine patient and hospital-level factors associated with treatment with IV/IM chemical restraint medications. Of 630,384 cases, 4.8% received IV/IM chemical restraint. Patient factors associated with higher odds of chemical restraint were older age (ages 13-17 years [adjusted odds ratio {AOR} 1.53, 95% confidence interval {CI} 1.48-1.58]), anxiety disorders (AOR 1.69, 95% CI 1.64-1.74), disruptive disorders (AOR 1.61, 95% CI 1.53-1.69), suicide/self-injury (AOR 1.3, 95% CI 1.26-1.34), substance use (AOR 1.24, 95% CI 1.20-1.28), and bipolar disorder (AOR 1.23, 95% CI 1.17-1.30). Participants with complex comorbidities were more likely to receive chemical restraint (AOR 1.32, 95% CI 1.26-1.39). After patient and hospital factors were adjusted for, the median OR indicating the influence of the individual hospital on the odds of chemical restraint was 1.43 (95% CI 1.40-1.47). We found that age and certain behavioral health diagnoses were associated with receipt of IV/IM chemical restraint during pediatric behavioral health ED visits. Additionally, whether a patient was treated with chemical restraints was strongly influenced by the hospital to which they presented for treatment.