Restraint and seclusion in psychiatric inpatient wards

PURPOSE OF REVIEW: Despite the controversy over the use of seclusion and restraint, these measures are commonly used to treat and manage disruptive and violent behaviour. This review summarizes recent research on the use of seclusion and restraint, and measures taken to reduce their use. RECENT FINDINGS: Lately, prominent international recommendations have aimed to restrict the use of seclusion and restraint, and reminded that they should only be used in exceptional cases, where there are no other means of remedying the situation and under the supervision of a doctor. The use of seclusion and restraint has remained prevalent, but there are serveral innovative programmes that have succeeded in controlling and reducing their use. Staff attitudes about seclusion and restraint have changed little in the last few years. SUMMARY: There is a need for novel methods to treat violence and the threat of violence on psychiatric wards. Violence is a complex phenomenon that needs to be met with a multiprofessional approach. Customer involvement in this work is required. The assessment of the effectiveness of programmes aiming to minimizing seclusion and restraint has been hampered by the lack of parallel control groups and there is a need for cluster-randomized trials. When studying these interventions, the safety of staff and patients should be included as on outcome measure.     

Patient interactions in four psychiatric wards

This article describes the interactions between patients and between patients and staff in 4 psychiatric wards. Two of the wards are acute admission units and 2 are for long-stay chronic patients. The hospital is diagnostically streamed so that not only does the average length of stay vary between wards but so, for one ward, does the predominant diagnostic group. Patient interactions were analysed in terms of 5 major interactional categories: individual verbal, individual nonverbal, group verbal, group nonverbal and physical. The results show that, although there was little change in the overall level of verbal interaction as a function of chronicity, there were large shifts in patient-patient and staff-patient interaction rates. Variations between the 4 wards on the 4 other interactional categories are explained in terms of the known diagnostic characteristics of the patients.     

Crowding and aggression on inpatient psychiatric wards.

The association between crowding and aggressive behavior among psychiatric inpatients was investigated. Aggressive incidents were documented on two closed psychiatric wards between February 1 and December 15, 1996. A modest correlation between number of patients on the ward and number of aggressive incidents per patient was found. Enlargement of the physical space by the addition of a courtyard to one of the wards midway through the study did not lead to a significant decline in incidents. Possibly, a lack of psychological space-having no privacy or not being able to get sufficient rest-may be more important in triggering aggression than a lack of physical space.     

Profile of psychiatric emergencies in general hospital wards

Statistical study, using objective variables, was carried out to draw the profile of psycho-social cases at the emergency unit of Publics hospitals. The study analyses the attitude of the nursing and medical staff. This paper looks the problem throw three parameters: the symptoms, the diagnosis and the final destination. The most important conclusion is: staff seems to see his work with emergencies cases like a shunting problem and not like a beginning of therapeutical work.     

Recognition of psychiatric disorders in nonpsychiatric hospital wards

OBJECTIVE: Although many studies have reported that many psychiatric cases are missed by their nonpsychiatric physicians, their methods are often limited because ward physicians' recognition has been assessed from potentially unreliable sources such as medical notes. The aim of the present study was to assess recognition by using direct questions to ward physicians. METHODS: Five hundred five (505) nonpsychiatric in-patients were interviewed using the Clinical Interview Schedule. Ward physicians' recognition of psychiatric disorders was assessed using a rating form for every patient. RESULTS: The psychiatric prevalence of the total sample was 37.3%. Overall, ward physicians' diagnostic sensitivity was 54.5%, but their sensitivity varied for the different diagnoses (31.3-89.5%). In addition to psychiatric symptoms and abnormalities, intake of psychotropics before admission significantly predicted identification of psychiatric disorders. CONCLUSIONS: In our study, physicians' sensitivity was higher than that reported from surveys based on medical notes. The fact that nearly half of all psychiatric disorders were missed by ward physicians suggests that better psychiatric training for nonpsychiatric doctors is necessary.     

Patterns of drug use in psychiatric inpatient wards.

Drug use was monitored in a total of 2,592 psychiatric inpatients in 6 hospitals. The efficacy was rated as satisfactory in 78% of the drug exposures. Nearly 37% of the patients had an adverse reaction. However, only 1.5% of the reactions were noted as being of major severity.     

Crowding and violence on psychiatric wards: explanatory models.

OBJECTIVE: Violence is widely prevalent on acute-care psychiatric wards, and crowding has been identified as a major risk factor. This paper explores why patients may respond to crowding with violence. METHOD: We carried out a literature review on Medline, using the key words "violence" and "crowding." We conducted an additional hand search of the references collected from the reviewed papers. RESULTS: Factors specific to the relation between crowding on acute-care inpatient psychiatric wards and violence can be divided under the following headings: 1) patient density, privacy, and control; 2) ward architecture; 3) the social organization of psychiatric wards; 4) interpersonal space; 5) phylogenic theories; and 6) anthropological theories of human behaviour. CONCLUSIONS: We offer explanatory models for this relation and suggest strategies to counter the effects of crowding. Recommendations are made for future studies.     

Staff injuries after patient-staff incidences in psychiatric acute wards

The aim of the study was to describe the pattern of injuries to various body parts in patient-staff incidents; 507 patient-staff incidents in a psychiatric acute ward during the period 1990-1997 were included. Staff members registered 193 injuries in the head, 112 in the trunk, 265 in the upper extremities and 69 in the lower extremities. No differences between the two sexes or between different levels of education among the nurses were found in the pattern of injuries. Doctors were more often injured in the head and less often injured in the upper extremity than the nurses. The head was more often injured when there was no understandable provocation before the incident and seldom injured when the patients were denied something. Injuries to the trunk were more frequently followed by use of parenteral medication. Parenteral medication and holding the patient with force were more frequently used in incidents where more than one body part was injured. The knowledge of injures after patient-staff incidences may contribute to the education and protective training of the staff of psychiatric acute wards.