The role of interpersonal style in aggression and its containment in a forensic mental health setting: A correlational and pseudoprospective study of patients and nursing staff

Inpatient aggression on mental health wards is common and staff–patient interactions are frequently reported antecedents to aggression. However, relatively little is known about the precise relationship between aggression and these interactions, or their relationships with aggression and staff containment responses such as restraint and seclusion. This study aimed to determine the roles of anger and interpersonal style among mental health nurses and between nurses and patients in the occurrence of aggression and its containment. A correlational, pseudoprospective study design was employed. n = 85 inpatients and n = 65 nurses were recruited from adult, low‐ and medium‐secure wards of a secure forensic mental health service. Participants completed validated self‐report anger and transactional interpersonal style measures. Inpatient aggression and containment incident data for a 3‐month follow‐up period were extracted from clinical records. Dyadic nurse–patient relationships were anticomplementary. Patients' self‐reported anger and staff‐rated hostile interpersonal style were significantly positively correlated; staff self‐reported anger and patient‐rated dominant interpersonal style were also positively correlated. Patient anger predicted aggression and their interpersonal style predicted being subject to containment in the form of restraint and seclusion. There were no statistically significant differences identified on measures between staff who were and were not involved in containment. More targeted intervention for patients' anger may have a positive impact on interpersonal style and lead to the reduction of incidents. Staff education and skills training programmes should emphasize the importance of interpersonal styles which could help to promote and enhance positive interactions.     

Children visiting parents in inpatient psychiatric facilities: perspectives of parents, carers, and children

A significant number of clients utilizing mental health services will also be parents. Being a child of a parent with mental illness increases health risks for the child, and hospitalization of the parent has been identified as one of the most difficult times for children. However, few proactive measures have been taken to understand or provide for the needs of children visiting psychiatric inpatient facilities. The aim of this exploratory study was to identify the perspectives children, their parents, nominated carers, and clinicians from their experience of children visiting. The study used qualitative data gathered from interviews to develop an understanding of the issues. The purpose of this paper was to present the findings from parents, carers, and children. Children indicated that they wanted to visit and to remain involved with their parent, but that there was little support from staff. Families indicated that children visiting psychiatric inpatient facilities were not well managed, and they received little support about decisions around children visiting. The issue of children visiting psychiatric facilities when they have a parent who is an inpatient appears not to have been addressed in models of inpatient mental health care.     

Predicting the Utilization of Intrusive Interventions at a Tertiary Residential Treatment Center

A model was tested to evaluate whether certain characteristics (sex, age at admission, abuse history, self harm history, externalizing, and functional impairment) can identify children/youth at highest risk for receiving intrusive interventions in residential care. Participants were 109 children/youth admitted to a tertiary mental health facility. The model predicted the receipt of intrusive interventions with 75.8% accuracy, identifying correctly 82.4% of the clients receiving intrusive interventions, and 68.2% not receiving any. The results indicated that younger males were more likely to be administered an intrusive intervention while in treatment, as well as those children/youth with a history of self harm.     

Experience coercion,post‐traumatic stress,and satisfaction with treatment associated with different coercive measures during psychiatric hospitalization

Coercive measures are frequently used in psychiatric hospitalization. However, there are few studies that analyse perceived coercion, post‐traumatic stress, and subjective satisfaction with the hospitalization treatment associated with different types of coercive measures. The sample consisted of 111 patients admitted to two psychiatric units and divided into three groups based on the measure applied: involuntary medication (N = 41), mechanical restraint (N = 32), and combined measures (mechanical restraint and involuntary medication; N = 38). The outcome variables were perceived coercion evaluated with the Coercion Experience Scale (CES), post‐traumatic stress evaluated with the Davidson Trauma Scale (DTS), and satisfaction with the treatment evaluated with the Client's Assessment of Treatment (CAT). The results found higher levels of perceived coercion associated with the use of mechanical restraint (P = 0.002) and combined measures (P < 0.001) in comparison with involuntary medication. Additionally, in relation to post‐traumatic stress, mechanical restraint (P = 0.013) and combined measures (P = 0.004) were more stressful compared to involuntary medication. Finally, the use of combined measures was associated with lower satisfaction with inpatient psychiatric treatment compared to the use of involuntary medication (P = 0.006). The following recommendation would be consistent with the results found: if a patient does not specify a preference for some type of measure, involuntary medication could be used and mechanical restraint avoided, especially when used in combination with involuntary medication.     

Early Identification of Seclusion and Restraint Patterns During Adolescents' Course of Residential Treatment

Early identification of youth who will exhibit the most challenging behavior during the course of a residential stay would allow clinicians to allocate limited resources to best manage these youth. Seclusion/restraint procedures were examined for 156 youth in two public residential facilities from July 2000–September 2005. Few seclusion/restraints occurred in the first month, but this peaked in months two and three. Youth subgroups with different trajectories for the frequency of seclusion/restraint use were distinguishable by the first 60 days. By the second month in residence clinicians can identify youth who will continue to exhibit challenging behavior.     

Minimizing Seclusion and Restraint in Youth Residential and Day Treatment Through Site-Wide Implementation of Collaborative Problem Solving

ABSTRACT

Despite a growing understanding of the need to reduce seclusion and restraint (S/R) in all types of youth psychiatric facilities, published accounts of success in the psychological literature have been limited to inpatient facilities. Furthermore, existing publications on successful S/R reduction rarely include details about implementation that would be helpful to other agencies looking to follow their lead. This article presents the case of one multiservice agency that reduced S/R rates in youth residential and day treatment programs after adopting the Collaborative Problem Solving (CPS) approach. It includes detailed information on implementation, data illustrating the reduction of S/R after CPS implementation, and discussion of possible benefits to youth outcomes and organizational costs.     

Classification and Diagnosis of Psychiatric Disorders in Persons with Developmental Disabilities

This article presents a brief historical overview of psychiatric diagnosis in persons with developmental disabilities, including a review of the relationship between applied behavior analysis and dual diagnosis. The purposes of diagnosis are then outlined. The definitions of developmental disabilities, mental disorder, and dual diagnosis are reviewed and some of the problems when making a psychiatric diagnosis in persons with developmental disabilities are discussed. Special attention is given to the problem of diagnosing mental retardation in persons with mild through borderline mental retardation and to the problem of diagnosing psychiatric disorders in persons with severe and profound mental retardation. Finally, an overview of common issues in the process of collecting and combining information to make a psychiatric diagnosis in persons with developmental disabilities is given.     

ICU患者身体约束使用现状调查与分析

目的：了解重症监护室（ICU）患者身体约束使用现状。方法：采用自行设计的《ICU患者身体约束调查表》回顾性调查102例ICU使用约束的成人患者资料,内容包括一般资料、疾病与治疗状况、身体约束特征、护理记录等。结果：ICU患者身体约束的使用率为45.7%,其中65岁及以上老年人占41.5%,精神心理状况异常者占13.2%,认知状况受损者占12.1%,镇静剂使用者占17.2%,机械通气者占75.2%;约束工具以手腕棉布约束带为主,部位以肢体约束为主;存在约束护理不规范、使用指征不明确、护理记录不全等问题。结论：应逐步明确患者身体约束的使用指征及护理内容,构建信息化管理系统,最终形成适用于我国临床护理工作的规范。     

Psychiatric nurses' thoughts and feelings about restraint use: a decision dilemma

Patients continue to be physically restrained in psychiatric in-patient units. Studies concerned with staff-related variables have suggested that the emotional reactions of professionals to violent or potentially violent patients may influence their use of restrictive measures. However, no research existed that described psychiatric nurses' thoughts and feelings while they were involved in restraint situations nor what effects their thoughts and feelings had on their decision to restrain. Therefore, an ethnographic qualitative study was conducted in order to describe systematically nurses' thoughts and feelings toward restraint use in the in-patient psychiatric setting. The conceptual approach guiding the study was Etzioni's (1992) theoretical work on the role of normative-affective factors in decision making. Following ethical approval of the study, ethnographic interviews were conducted with six nurses from an in-patient psychiatric unit who had participated in a situation involving the physical restraint of a patient. The analysis of the nurses' thoughts and feelings revealed that the restraint situation represented a decision dilemma for them. This overall finding was supported by four themes: (1) the framing of the situation: the potential for imminent harm; (2) the unsuccessful search for alternatives to physical restraints; (3) the conflicted nurse; and (4) the contextual conditions of restraint. The results indicated that restraint use is more complex than is currently conveyed in the literature in that normative-affective factors influenced nurses' restraint decisions. The findings advance our understanding of why restraints continue to be used in psychiatric units. Further research is necessary to examine the findings in other settings and with a larger and more diverse population in order to draw definitive conclusions about the continued use of physical restraints in the care of patients on psychiatric units in hospitals.     

Prolonged use of seclusion and mechanical restraint in mental health services: A statewide retrospective cohort study

Seclusion and mechanical restraint are restrictive interventions that should be used only as a last resort and for the shortest possible time, yet little is known about duration of use in the broader context. Adult area mental health services throughout Victoria, Australia, were asked to complete a report form for prolonged episodes of seclusion (>8 hours) and mechanical restraint (>1 hour). The present, retrospective cohort study aimed to understand the individual (age, sex, type of service, duration of intervention) and contextual factors associated with prolonged use of restrictive interventions. Contextual factors describing the reasons for prolonged use of the restrictive interventions were captured qualitatively, and then coded using content analysis. Median duration was compared across individual factors using Mann–Whitney U‐tests. During 2014, 690 episodes of prolonged restrictive intervention involving 311 consumers were reported. Close to half (n = 320, 46%) involved mechanical restraint. Seclusion episodes (n = 370) were longer in forensic mental health services compared to adult area mental health services (median: 24 hours and 18 min vs 16 hours and 42 min, P < 0.001). Mechanical restraint episodes (n = 320) were shorter in forensic mental health services compared to adult area mental health services (median: 3 hours and 25 min vs 4 hours and 15 min, P = 0.008). Some consumers were subject to multiple episodes of prolonged seclusion (55/206, 27%) and/or prolonged mechanical restraint (31/131, 24%). The most commonly occurring contextual factor for prolonged restrictive interventions was ‘risk of harm to others’. Means for reducing the use of prolonged restrictive interventions are discussed in light of the findings.     

Prosocial Behavior Is a Relative Strength in Siblings of Children with Physical Disabilities or Autism Spectrum Disorder

Research on siblings of children with developmental and physical disabilities has emphasized negative influences on siblings’ mental health. Yet, such siblings may be more prosocial compared with siblings of children without disabilities, due to care responsibilities and their experiences with their brother’s or sister’s disability. We compared prosocial behavior between siblings of children with autism spectrum disorder (ASD; n?=?47), physical disabilities (n?=?42), and siblings of children without disabilities (n?=?44) using a multi-informant approach (i.e., child-, mother-, and father-report). Prosocial behavior was measured with the Strengths and Difficulties Questionnaire. Drawing on the theoretical and empirical sibling literature, we also examined whether siblings’ internalizing and externalizing difficulties, adjustment to the sibling situation, and communication with parents correlated with siblings’ prosocial behavior. Child-reported internalizing difficulties and mother–child communication significantly correlated with mother-reported prosocial behavior. Child-reported internalizing and externalizing difficulties significantly correlated with father-reported prosocial behavior. No significant correlates with child-reported prosocial behavior was identified. When adjusting for siblings’ internalizing and externalizing difficulties and mother–child communication, siblings of children with physical disabilities scored significantly higher than siblings of children without disabilities on mother- and father-reported prosocial behavior. Siblings of children with ASD scored significantly higher on mother-reported prosocial behavior. We conclude that prosocial behavior may be a relative strength in siblings of children with developmental and physical disabilities, and that siblings’ prosocial behavior may be influenced by type of disability, mental health, and family communication. Interventions targeting siblings’ mental health and family communication may be helpful in promoting siblings’ prosocial behavior.

     

Respiratory Assessment in Child and Adolescent Residential Treatment Settings: Reducing Restraint-Associated Risks

TOPIC: Crisis situations of youth in treatment settings may require restraints. Restraints should only be used in situations where there is imminent danger to the child and when there is no alternative. They are meant to maintain the child's safety, but there is risk for respiratory compromise. PURPOSE: Nursing care of children in restraints must include respiratory assessment and, when indicated, immediate intervention to prevent disastrous outcomes. SOURCES: Review using PubMed and established texts confirms that clinical skills and knowledge is essential to child and adolescent psychiatric nursing. CONCLUSIONS: Clinical assessment and awareness of risks in physical restraints is essential for the safety and well-being of the child.     

Effectiveness of Six Core Strategies Based on Trauma Informed Care in Reducing Seclusions and Restraints at a Child and Adolescent Psychiatric Hospital

OBJECTIVE: The purpose of the study was to determine the effectiveness of six core strategies based on trauma informed care in reducing the use of seclusion and restraints with hospitalized youth. METHODS: The hospital staff received training in March 2005 in six core strategies that are based on trauma informed care. Medical records were reviewed for youth admitted between July 2004 and March 2007. Data were collected on demographics, including age, gender, ethnicity, number of admissions, type of admissions, length of stay, psychiatric diagnosis, number of seclusions, and restraints. RESULTS: Four hundred fifty‐eight youth (females 276/males 182) were admitted between July 2004 and March 2007. Seventy‐nine patients or 17.2% (females 44/males 35) required 278 seclusions/restraints (159 seclusions/119 restraints), with average number of episodes 3.5/patient (range 1–28). Thirty‐seven children and adolescents placed in seclusion and/or restraints had three or more episodes. In the first six months of study, the number of seclusions/restraints episodes were 93 (73 seclusions/20 restraints), involving 22 children and adolescents (females 11/males 11). Comparatively, in final six months of study following the training program, there were 31 episodes (6 seclusions/25 restraints) involving 11 children and adolescents (females 7/males 4). The major diagnoses of the youth placed in seclusion and/or restraints were disruptive behavior disorders (61%) and mood disorders (52%). CONCLUSIONS: This study shows downward trend in seclusions/restraints among hospitalized youth after implementation of National Association of State Mental Health Program Directors six core strategies based on trauma informed care.     

The role of public health nurses in service delivery to youth with mental disabilities

Background: The mental health needs of children and adolescents are not being adequately addressed.Objectives: To describe the roles of public health nurses in the care of children and adolescents with mental disabilities and to explore incentives and barriers to expansion of the role in the care of this population.Methods: Directors of nursing of public health agencies and executive directors of mental health agencies in Ohio responded to a mailed survey.Results: The majority of respondents reported that public health nurses currently work with youth with mental disabilities, primarily in the roles of referral and providing physical health care. Both groups of directors saw potential for increasing roles—provided public health nurses received education and consultation. Both groups reported that barriers to expanding public health nurses' roles were the organization and funding of mental and public health systems.Conclusion: Although better utilization of public health nurses could improve children's health care and make more efficient use of scarce specialty mental health resources, financial and organizational barriers present significant challenges to collaboration.     

A Meta-Analytic Review of Mental Health Interventions Targeting Youth with Internalizing Disorders in Juvenile Justice Facilities

There is general agreement in the research literature that youth in juvenile justice facilities are more likely to experience mental health disorders than their general population peers. The purpose of this systematic review and meta-analysis was to evaluate the methodological characteristics and effectiveness of mental health interventions delivered in juvenile justice settings on symptoms associated with internalizing disorders. The 11 studies included in the current review incorporated pretest-posttest research designs and were conducted with juveniles in secure facilities that reported outcome measures of depression, anxiety, posttraumatic stress disorder, or internalizing disorders. Meta-analytic findings indicate mixed results for interventions affecting internalizing symptoms and varying results between studies implementing an experimental design compared to those using a single group non-experimental design. Additionally, no studies examined how interventions could be incorporated into daily activities in juvenile justice facilities, such as school and classroom activities. Lastly, the limited number of studies included in the current review indicates a continued need for further experimental research on the effectiveness of mental health interventions delivered to youth in juvenile justice facilities.     

Multidimensional approach to restraint minimization: The journey of a specialized mental health organization

The executive‐level witnessing and review of restraint events has been identified as a key strategy for restraint minimization. In the present study, we examined the changes in restraint practices at a tertiary‐level mental health‐care facility with implementation of an initiative, in which representatives from senior management, professional practice, peer support, and clinical ethics witnessed seclusion and restraint events, and rounded with clinical teams to discuss timely release and brainstorm prevention strategies. Interrupted time series analysis compared the change from pre‐implementation (14 months prior) to postimplementation (35 months’ following) in the number of incidents/month, total hours/month, and average hours/incident/month for each of seclusion and mechanical restraint. With implementation, there was a step decrease in average hours/seclusion (–28.3 hours/seclusion, P < 0.001) and total seclusion hours (–1264.5 hours, P = 0.002). The postimplementation rate of decrease of –0.9 hours/incident/month was different than the pre‐implementation rate of increase of 0.7 hours/incident/month for mechanical restraint (P = 0.03). Pre‐implementation, there was a rate of decrease of 6.1 incidents/month (P < 0.001) and 4.5 incidents/month (P = 0.001) for seclusion and mechanical restraint, respectively. Postimplementation, there was a rate of increase of 0.3 incidents/month and a rate of decrease of 0.05 incidents/month for seclusion and mechanical restraint, respectively, both of which were different than pre‐implementation (seclusion: P < 0.001, mechanical restraint: P = 0.002). In conclusion, the total hours of seclusion and average hours per seclusion and per restraint incident were reduced, demonstrating the value of leadership witnessing and daily rounds in promoting restraint minimization in tertiary‐level mental health care.     

Views of nursing staff on the use of physical restraint

A postal questionnaire survey was employed in regional secure and psychiatric intensive care units in England and Wales, in respect of mental health nurses' training in the use of physical restraint. The nurses' views were sought relating to their last experience of implementing the procedure. Whilst most nurses (n = 259, 96.3%) reported positive outcomes in so far that the incident was brought under control, the views of the aftereffects of the procedure were of concern and ambivalence. The literature suggests that service users did not necessarily hold the same positive views. A range of alternatives, which were consistent with the literature, was made by staff to improve intervention in the management of violence. Negative aspects relating to the use of physical restraint were also highlighted. They included procedural, injury, clinical and management issues. Some respondents also expressed concerns about the negative attitudes of their colleagues. The findings of this aspect of the survey highlights that the therapeutic value of physical restraint can only be achieved with appropriate monitoring and with emphasis on psychological intervention in the prevention and management of violence.