Use Of Restrictive Practices Research Articles

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.

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.

'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.

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.

Research to reduce the use of restrictive practices: a response to recommendation 6.38 of the Disability Royal Commission

The Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability was concerned by the level of restrictive practices revealed in the evidence it received. As one of its recommendations, it suggested that a study be commissioned to examine the effectiveness of Positive Behaviour Support in reducing the use of these practices. In this article, we argue that Positive Behaviour Support is aimed at reducing behaviours of concern rather than restrictive practices and that these should not be conflated. We provide a discussion of some of the research design issues that need to be addressed if an investigation of ways to reduce reliance on restrictive practices is to be carried out.

The Maintenance Model of Restrictive Practices: A Trauma-Informed, Integrated Model to Explain Repeated Use of Restrictive Practices in Mental Health Care Settings

Nurses are at the forefront of care in mental health services but their role is conflicted; they carry the most responsibility for care and also for restrictive practices. The harmful effects of restrictive practices for mental health patients are well documented, have attracted negative media attention, public concern, and criticism directed specifically at nursing staff. The need to reduce restrictive practices has been highlighted by patients, carer groups, legislators, policy makers, academics, and mental health service providers. Policies and best practice guidelines have resulted, but restrictive practices remain a global problem. This theory paper proposes that inertia is partly due to the absence of a coherent model that explains the initiation and maintenance of restrictive practice in inpatient mental health settings. The conceptual development and synthesis of the model and its practical implications are discussed.

Co-designing restrictive practice elimination: A systems thinking approach with mental health service users and practitioners in rural/regional Australia.

Elimination of restrictive practices (physical/mechanical restraint and seclusion) from adult acute mental health care services has been demanded internationally for many decades. This study aimed to: (1) Identify priority issues in the elimination of and use of alternative approaches to restrictive practices (seclusion and physical/mechanical restraint) in rural/regional acute adult mental healthcare services, as told by mental healthcare service users and practitioners, (2) identify the community-based, system-level feedback loops that enhance or reduce the use of restrictive practices and viable alternatives and, (3) identify potential action areas to improve system structures to increase regional mental healthcare services' ability to eliminate restrictive practices and use alternative approaches. Group model building (GMB) workshops were held with a small group (n = 9) of mental healthcare practitioners and service users with lived experience of restrictive practice use. This participatory approach enables exploration and visual mapping of local structures causing behaviour patterns of practitioner and service user concern over time - in this case, the barriers, and enablers to alternative approaches to restrictive practices in adult acute mental healthcare services within the Geelong-Barwon region. This is the first study that specifically applies GMB in the discussion of the elimination of restrictive practices in mental health in the non-metropolitan regional/rural context. Participants identified four key priorities in relation to eliminating restrictive practices: (1) self-advocacy, (2) continuity of care, (3) early intervention, and (4) safety for all. The study findings were distilled into a novel preliminary set of mental healthcare practitioner and service user action ideas.

Restrictive practices in community services for people with intellectual disabilities at risk of behaviours that challenge: insights and omissions of the Disability Royal Commission

People with intellectual disabilities commonly experience violent, abusive, and restrictive contexts, particularly those who are at risk of behaviours that challenge, behaviours that often are a sign of trauma, fear, pain, and loss of power. For example, the use of physical restraint and psychotropic medication to manage behaviours labelled as challenging is prevalent in services for people with intellectual disabilities, and has a negative impact on their wellbeing and quality of life. The Australian Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability has recommended a reduction in the use of restrictive practices, and that they only be used as a last resort. However, there is a risk that a narrow focus on behaviours labelled as challenging and their management through legislation, procedures, and authorisation by writing behavioural support plans fails to properly address the concerns of people with intellectual disabilities at risk of behaviours that challenge. There might not be enough incentive for the system-wide change required to properly meet the needs of this specific group. The closure of group homes, as recommended by the Commission, is appealing, given that abusive and restrictive practices are repeatedly uncovered in these settings. However, this might add to the precarious situation unless significant social change is made. Instead, perhaps more feasible, a plan to enable group homes become truly a home, safe and with highly skilled support available, should be developed. A framework based on the concept of capable environments might aid in this endeavour.

Developing entrustable professional activities to enhance application of an aggression prevention protocol

AimThe research aim of this study was to seek feedback from prevention of aggression training experts about the suitability of Entrustable Professional Activities (EPAs) as an assessment tool for an Aggression Prevention Protocol. The protocol was designed to structure intervention to prevent aggression and reduce the use of restrictive practices following risk assessment using a validated instrument (the Dynamic Appraisal of Situational Aggression). BackgroundPreventing aggression and limiting the use of restrictive practices are key priorities for inpatient mental health services. Assessing clinical activities using a competence framework has limitations, particularly when determining complex interventions. EPAs could provide a suitable method for assessing complex clinical activities like de-escalation and limit setting, which comprise some of the interventions in the Aggression Prevention Protocol. EPAs are new to forensic mental health nursing; therefore, feedback was sought regarding the utility of EPAs to assess aggression prevention interventions. MethodsData were collected via focus groups including 11 aggression prevention experts from Australia and New Zealand. A thematic analysis, comparative analysis and a Strength, Weakness, Opportunity and Threats analysis was conducted. ResultsThree themes were interpreted from the data: 1) Frameworks such as the APP are needed to work towards elimination of restrictive practices; 2) APP-EPAs afford an opportunity to set the standard for practice; and 3) ‘who watches the watchers’, were identified by the experts as well as areas to enhance EPAs prior to introduction into practice. ConclusionsEPAs address a practice-gap and offer a framework to assist movement towards elimination of restrictive practices, while prompting best-practice, self-reflection and practice improvement guidance.

Barriers and enablers to the implementation of Safewards and the alignment to the i-PARIHS framework - A qualitative systematic review.

Inpatient mental healthcare settings should offer safe environments for patients to heal and recover and for staff to provide high-quality treatment and care. However, aggressive patient behaviour, unengaged staff approaches, and the use of restrictive practices are frequently reported. The Safewards model includes ten interventions that aim to prevent conflict and containment. The model has shown promising results but at the same time often presents challenges to successful implementation strategies. The aim of this study was to review qualitative knowledge on staff experiences of barriers and enablers to the implementation of Safewards, from the perspective of implementation science and the i-PARIHS framework. A search of the Web of Science, ASSIA, Cochrane Library, SCOPUS, Medline, Embase, PsycINFO, and CINAHL databases resulted in 10 articles. A deductive framework analysis approach was used to identify barriers and enablers and the alignment to the i-PARIHS. Data most represented by the i-PARIHS were related to the following: local-level formal and informal leadership support, innovation degree of fit with existing practice and values, and recipients' values and beliefs. This indicates that if a ward or organization wants to implement Safewards and direct limited resources to only a few implementation determinants, these three may be worth considering. Data representing levels of external health system and organizational contexts were rare. In contrast, data relating to local (ward)-level contexts was highly represented which may reflect Safewards's focus on quality improvement strategies on a local rather than organizational level.

An argumentation analysis of testimony about positive behaviour support and chemical restraint in Australia’s Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability

Introduction Australia’s Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability (2019–2023) is examining, amongst many issues, how positive behaviour support (PBS) can address challenging behaviour and reduce the use of restrictive practices, particularly chemical restraint. This study explores the basis of the claims made about this during testimony. Materials and methods Applying existing recommendations for the study of Royal Commissions, this study uses argumentation analysis of testimony. Results Three central claims about PBS were identified: practitioners, behaviour support plans, and chemical restraint. Comparison with Australian research shows preparation of behaviour support practitioners is poor, behaviour support plans do not show a clear benefit to people with disability, and chemical restraint remains a persisting issue with no viable way forward. Discussion The analysis highlights the difference between perceptions of PBS and the current Australian evidence underlying it. The barriers to the promotion of PBS to address restrictive practices in Australian disability services prompts reconsideration of the policy expansion to address restrictive practices in other sectors.

Trauma Informed Interventions to Reduce Seclusion, Restraint and Restrictive Practices Amongst Staff Caring for Children and Adolescents with Challenging Behaviours: A Systematic Review

Engaging with children and adolescents in mental health settings who are exhibiting behaviours that challenge can often result in the use of seclusion, restraint and coercive practices. It is recognised that more therapeutic ways to engage this population are needed, adopting trauma informed interventions may provide a solution. The aim of this systematic review is to synthesize the evidence in relation to the effect of trauma-informed interventions on coercive practices in child and adolescent residential settings. The review is guided by elements of the Cochrane Handbook for Systematic Reviews of Interventions and reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist. Results were synthesized and reported narratively. Nine studies met the eligibility criteria for this review. There was a lack of homogeneity amongst the studies. The trauma-informed interventions used were typically multi-faceted, underpinned by a variety of approaches and sought to bring about changes to clinical practice. Most studies (n = 8) reported significant reductions in the use of restrictive practices following the implementation of a trauma informed approach. The use of a trauma-informed approach, underpinned by an organisational change or implementation strategy, have the potential to reduce coercive practices with children and adolescents. However, the included interventions were insufficiently described to draw strong conclusions.

Focusing on the legal, ethical and practical issues in the use of restrictive practices

Focusing on the legal, ethical and practical issues in the use of restrictive practices

Focusing on the legal, ethical and practical issues in the use of restrictive practices

Focusing on the legal, ethical and practical issues in the use of restrictive practices

Ethnic disparities in the use of restrictive practices in adult mental health inpatient settings: a scoping review.

To identify and summarise extant knowledge about patient ethnicity and the use of various types of restrictive practices in adult mental health inpatient settings. A scoping review methodological framework recommended by the JBI was used. A systematic search was conducted in APA PsycINFO, CINAHL with Full Text, Embase, PubMed and Scopus. Additionally, grey literature searches were conducted in Google, OpenGrey and selected websites, and the reference lists of included studies were explored. Altogether, 38 studies were included: 34 were primary studies; 4, reviews. The geographical settings were as follows: Europe (n = 26), Western Pacific (n = 8), Americas (n = 3) and South-East Asia (n = 1). In primary studies, ethnicity was reported according to migrant/national status (n = 16), mixed categories (n = 12), indigenous vs. non-indigenous (n = 5), region of origin (n = 1), sub-categories of indigenous people (n = 1) and religion (n = 1). In reviews, ethnicity was not comparable. The categories of restrictive practices included seclusion, which was widely reported across the studies (n = 20), multiple restrictive practices studied concurrently (n = 17), mechanical restraint (n = 8), rapid tranquillisation (n = 7) and manual restraint (n = 1). Ethnic disparities in restrictive practice use in adult mental health inpatient settings has received some scholarly attention. Evidence suggests that certain ethnic minorities were more likely to experience restrictive practices than other groups. However, extant research was characterised by a lack of consensus and continuity. Furthermore, widely different definitions of ethnicity and restrictive practices were used, which hampers researchers' and clinicians' understanding of the issue. Further research in this field may improve mental health practice.

Approaches used to prevent and reduce the use of restrictive practices on adults with learning disabilities: Protocol for a realist review.

The use of restrictive practices has significant adverse effects on the individual, care providers and organisations. This review will describe how, why, for whom, and in what circumstances approaches used by healthcare organisations work to prevent and reduce the use of restrictive practices on adults with learning disabilities. Evidence from the literature will be synthesised using a realist review approach - an interpretative, theory-driven approach to understand how complex healthcare approaches work in reducing the use of restrictive practices in these settings. In step 1, existing theories will be located to explore what approaches work by consulting with key topic experts, holding consultation workshops with healthcare professionals, academics, and experts by experience, and performing an informal search to help develop an initial programme theory. A systematic search will be performed in the second step in electronic databases. Further searches will be performed iteratively to test particular subcomponents of the initial programme theory, which will also include the use of the CLUSTER approach. Evidence judged as relevant and rigorous will be used to test the initial programme theory. In step three, data will be extracted and coded inductively and deductively. The final step will involve using a realist logic of analysis to refine the initial programme theory in light of evidence. This will then provide a basis to describe and explain what key approaches work, why, how and in what circumstances in preventing and reducing the use of restrictive practices in adults with learning disabilities in healthcare settings. Findings will be used to provide recommendations for practice and policymaking. In accordance with the guidelines, this realist review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 4th December 2019 (CRD42019158432).

Spanish mental health nurses' experiences of mechanical restraint: A qualitative descriptive study.

INTRODUCTION: Mechanical restraint is an intervention that causes harm to service users and nurses, yet continues to be used in many countries, including Spain. However, there is a lack of research exploring Spanish mental health nurses' experiences of using mechanical restraint. To describe the experiences of mental health nurses who have used mechanical restraint in practice. A qualitative descriptive methodology was used and a purposive sample of 10 Spanish mental health nurses were interviewed about their experiences of using mechanical restraint. Thematic analysis was then employed to analyse interview data. Participants' experiences of using mechanical restraint were mostly negative. Three main themes arose from the analysis of interview transcripts, (i) symmetrical trauma, (ii) moral injury and (iii) broken trust. The use of restrictive practices, which can be perceived as counter-therapeutic, exposes nurses to risks such as moral injury and service users to broken trust in the therapeutic nurse patient relationship. Avoiding empathy in order to use mechanical restraint is counterproductive, in the understanding that empathy is key to reducing this intervention. Reducing or eliminating use of mechanical restraints should be a policy and practice priority due to the symmetrical harms it causes both nurses and service users. The trust aspect of the therapeutic nurse-patient relationship is a significant casualty when mechanical restraint is used, therefore involving service users in co-production of post-mechanical restraint debriefing can be an avenue for restoring this trust through dialogue.

Reducing the use of restrictive practices by applying a human rights-based approach

Reducing the use of restrictive practices by applying a human rights-based approach

Mapping review of interventions to reduce the use of restrictive practices in children and young people's institutional settings: The CONTRAST study.

Restrictive practices are often used harmfully with children in institutional settings. Interventions to reduce their use do not appear to have been mapped systematically. Using environmental scanning, we conducted a broad-scope mapping review of English language academic databases, websites and social media, using systematic methods. Included records (N= 121) were mostly from the United States and contained details of 82 different interventions. Children's participation was limited. Reporting quality was inconsistent, which undermined claims of effectiveness. Overall, despite a multitude of interventions, evidence is limited. Leaders should consider the evidence, including children's perspectives, before introducing poorly understood interventions into children's settings.