Hostname: page-component-78c5997874-v9fdk Total loading time: 0 Render date: 2024-11-10T13:11:07.916Z Has data issue: false hasContentIssue false

Seclusion and restraint usage in seven English psychiatric intensive care units (PICUs)

Published online by Cambridge University Press:  01 December 2009

Stephen Dye
Affiliation:
Consultant Psychiatrist, Suffolk Mental Health Partnership NHS Trust
Steve Brown
Affiliation:
Consultant Psychiatrist, Hampshire Partnership NHS Trust
Navjyoat Chhina
Affiliation:
Specialist Registrar, General Adult Psychiatry, Oxford Deanery
Get access

Abstract

Background: Psychiatric intensive care units (PICUs) provide care for patients who may demonstrate agitation and aggressive tendencies. Such behaviour has traditionally been managed using interventions such as seclusion and/or physical restraint. There is little published data about the use of these measures within different PICUs. This paper attempts to provide such evidence as a base for clinical governance.

Aims: To describe patterns of seclusion and restraint usage within the care of 332 patients admitted consecutively to seven English PICUs.

Method: Prospective, multi-centre patient case note analysis.

Results: Within the four units that utilised seclusion in the study period, it was used on 16% of patients who had been admitted. All seven units used control and restraint and 28% of admitted patients were formally restrained at some point during their admission. There was no significant difference in mean duration of restraint or proportion of patients who were restrained between the units that used seclusion and those that did not. Use of seclusion was significantly associated with patient violence and property damage in PICU. Restraint usage was also significantly associated with patient violence and property damage but also with higher two week BPRS scores and a younger patient age.

Conclusions: It appears that PICUs manage disturbed behaviour differently, either dependent upon facilities or local policies. In attempting to reduce the use of seclusion and restraint, a multi-faceted approach must be taken both locally and nationally. PICU clinicians and service users should be integral within this.

Type
Original Paper
Copyright
Copyright © NAPICU 2009

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Abdelmawla, N. and Mitchell, A. (2006) Sudden cardiac death and antipsychotics. Part 2: Monitoring and prevention. Advances in Psychiatric Treatment. 12: 100109.CrossRefGoogle Scholar
Antonelli, M. (2008) Restraint management: Moving from outcome to process. Journal of Nursing Care Quality. 23(3): 227232.CrossRefGoogle ScholarPubMed
Bowers, L., Brennan, G., Flood, C., Lipang, M. and Oladapo, P. (2006) Preliminary outcomes of a trial to reduce conflict and containment on acute psychiatric wards: City Nurses. Journal of Psychiatric & Mental Health Nursing. 13(2): 165172.CrossRefGoogle ScholarPubMed
Bowers, L., van der Werf, B., Vokkolainen, A., Muir-Cochrane, E., Allan, T. and Alexander, J. (2007a) International variation in containment measures for disturbed psychiatric inpatients: A comparative questionnaire survey. International Journal of Nursing Studies. 44(3): 357364.CrossRefGoogle ScholarPubMed
Bowers, L., Hackney, D., Nijman, H., Grange, A., Allan, T., Simpson, A., Hall, C. and Eyres, S. (2007b) A Longitudinal Study of Conflict and Containment on Acute Psychiatric Wards. Report to DH Policy Research Programme. London: City University.Google Scholar
Brown, S., Chhina, N. and Dye, S. (2008) The psychiatric intensive care unit: A prospective survey of patient demographics and outcomes at seven English PICUs. Journal of Psychiatric Intensive Care. 4(1–2): 1727.CrossRefGoogle Scholar
Brown, S., Chhina, N. and Dye, S. (2009) The use of psychotropic medication in seven English psychiatric intensive care units (PICUs). Psychiatric Bulletin. [details tbc]Google Scholar
Champagne, T. and Stromberg, N. (2004) Sensory approaches in inpatient psychiatric settings: Innovative alternatives to seclusion and restraint. Journal of Psychosocial Nursing & Mental Health Services. 42(9): 3544.CrossRefGoogle ScholarPubMed
Cohen, D.P., Akhtar, M.S., Siddiqui, A., Shelley, C., Larkin, C., Kinsella, A., O'Callaghan, E. and Lane, A. (2008) Aggressive incidents on a psychiatric intensive care unit. Psychiatric Bulletin. 32: 452454.CrossRefGoogle Scholar
Dale, C., O'Hare, G. and Rae, M. (2006) The NIMHE/NPSA Project on the Prevention and Management of Aggression and Violence in Mental Health Services Final Report. www.virtualward.org.ukGoogle Scholar
Department of Health (1999) Code of Practice, Mental Health Act, 1983. London: HMSO.Google Scholar
Department of Health (2002) Mental Health Policy Implementation Guide for National Minimum Standards for General Adult Services in Psychiatric Intensive Care Units (PICU) and Low Secure Environments. London: Department of Health.Google Scholar
Duxbury, J. (2002) An evaluation of staff and patient views of and strategies employed to manage inpatient aggression and violence on one mental health unit: A pluralistic design. Journal of Psychiatric & Mental Health Nursing. 9(3): 325337.CrossRefGoogle ScholarPubMed
Dye, S., Johnston, A. and Pereira, S. (2005) The national psychiatric intensive care governance network 2004–5. Journal of Psychiatric Intensive Care. 1: 97104.CrossRefGoogle Scholar
El-Badri, S.M. and Mellsop, G. (2002) A study of the use of seclusion in an acute psychiatric service. Australian and New Zealand Journal of Psychiatry. 36(3): 399403.CrossRefGoogle Scholar
Farrell, G. and Cubit, K. (2005) Nurses under threat: A comparison of content of 28 aggression management programs. International Journal of Mental Health Nursing. 14(1): 4453.CrossRefGoogle ScholarPubMed
Fisher, W. (2003) Elements of successful restraint and seclusion reduction programs and their application in a large, urban, state psychiatric hospital. Journal of Psychiatric Practice. 9(1): 715.CrossRefGoogle Scholar
Flaherty, J. and Meagher, R. (1980) Measuring racial bias in inpatient treatment. American Journal of Psychiatry. 137: 679682.Google ScholarPubMed
Forster, P.L., Cavness, C. and Phelps, M.A. (1999) Staff training decreases the use of seclusion and restraint in an acute psychiatric hospital. Archives of Psychiatric Nursing. 13(5): 269271.CrossRefGoogle Scholar
Freuh, B.C., Knapp, R.G., Cusack, K.J., Grubaugh, A.L., Sauvageot, J.A., Cousins, V.C., Yim, E., Robins, C.S., Monnier, J. and Hiers, T.G. (2005) Patients' reports of traumatic or harmful experiences within the psychiatric setting. Psychiatric Services. 56: 11231133.CrossRefGoogle Scholar
Gaskin, C.J., Caderyn, J., Elsom, S. and Happell, B. (2007) Interventions for reducing the use of seclusion in psychiatric facilities: Review of the literature British Journal of Psychiatry. 191: 298303.CrossRefGoogle ScholarPubMed
Gudjonsson, G.H., Rabe-Hesketh, S. and Wilson, C. (2000) Violent incidents in a psychiatric hospital. The target of assault and the management of incidents. Journal of Forensic Psychiatry. 11: 105118.CrossRefGoogle Scholar
Gudjonsson, G.H., Rabe-Hesketh, S. and Szmukler, G. (2004) Management of psychiatric in-patient violence: Patient ethnicity and use of medication, restraint and seclusion. British Journal of Psychiatry. 184: 258262.CrossRefGoogle ScholarPubMed
Hafner, R.J., Lammersma, J., Ferris, R. and Cameron, M. (1989) The use of seclusion: A comparison of two psychiatric intensive care units. Australian and New Zealand Journal of Psychiatry. 23(2): 235239.CrossRefGoogle ScholarPubMed
Healthcare Commission (2008) National Audit of Violence 2006–7 Final Report – Working age adult services. London: Healthcare Commission.Google Scholar
Hellerstein, D.J., Staub, A.B. and Lequesne, E. (2007) Decreasing the use of restraint and seclusion among psychiatric inpatients. Journal of Psychiatric Practice. 13(5): 308317.CrossRefGoogle ScholarPubMed
HSE (2006) Violence and Aggression Management Training for Trainers and Managers: A national evaluation of the training provision in healthcare settings. London: HMSO.Google Scholar
Hucksorn, K. (2006) Re-designing State mental health policy to prevent the use of seclusion and restraint. Administration & Policy in Mental Health. 33(4): 482491.CrossRefGoogle Scholar
Janner, M. (2007) From the inside out: Star Wards – lessons from within acute in-patient wards. Journal of Psychiatric Intensive Care. 3(2): 7578.CrossRefGoogle Scholar
Klinge, A. (1994) Staff opinions about seclusion and restraint at a state forensic hospital. Hospital & Community Psychiatry. 45: 138141.Google Scholar
Lukoff, D., Nuechterlein, K. and Ventura, J. (1986) Manual for expanded Brief Psychiatric Rating Scale (BPRS). Schizophrenia Bulletin. 12: 594602.Google Scholar
Macpherson, R., Dix, R. and Morgan, S. (2005) A growing evidence base for management guidelines, revisiting… guidelines for the management of acutely disturbed psychiatric patients. Advances in Psychiatric Treatment. 11(6): 404415.CrossRefGoogle Scholar
Meehan, T., Bergen, H. and Fjeldsoe, K. (2004) Staff perceptions of seclusion: Has anything changed? Journal of Advanced Nursing. 47(1): 3338.CrossRefGoogle ScholarPubMed
Morrison, P. and Lehane, M. (1995) Staffing levels and seclusion use. Journal of Advanced Nursing. 55: 11931202.CrossRefGoogle Scholar
Nelstrop, L., Chandler-Oatts, J., Bingley, W., Bleetman, T., Corr, F., Cronin-Davis, J., Fraher, D.M., Hardy, P., Jones, S., Gournay, K., Johnston, S., Pereira, S., Pratt, P., Tucker, R. and Tsuchiya, A. (2006) A systematic review of the safety and effectiveness of restraint and seclusion as interventions for the short-term management of violence in adult psychiatric inpatient settings and emergency departments. Worldviews on Evidence-Based Nursing. 3(1): 818.CrossRefGoogle ScholarPubMed
NHS London (2006) Report of the External Review of John Meyer Ward Following the Death of Eshan Chattun. London: NHS London.Google Scholar
NICE (2005) Violence. The short-term management of disturbed/violent behaviour in psychiatric in-patient settings and emergency departments. London: NICE.Google Scholar
Nijman, H.L.I., à Campo, J.M.L.G., Ravelli, D.P. and Merckelbach, H.L.G.J. (1999) A tentative model of aggression on inpatient psychiatric wards. Psychiatric Services. 50: 832834.CrossRefGoogle ScholarPubMed
NIMHE (2004) Mental Health Policy Implementation Guide: Developing positive practice to support the safe and therapeutic management of aggression and violence in mental health in-patient settings. London: NIMHE.Google Scholar
Norfolk, Suffolk and Cambridgeshire SHA (2003) Independent Inquiry into the Death of David Bennett.Google Scholar
Nyberg-Coles, M. (2005) Promoting safer and therapeutic services. Mental Health Practice. 8(7): 1617.CrossRefGoogle Scholar
Outlaw, F.H. and Lowery, B.J. (1992) Seclusion: The nursing challenge. Journal of Psychosocial Nursing & Mental Health Services. 30(4): 1317.CrossRefGoogle ScholarPubMed
Palmstierna, T. and Wistedt, B. (1995) Changes in the pattern of aggressive behaviour among inpatients with changed ward organisation. Acta Psychiatrica Scandinavica. 91: 3235.CrossRefGoogle Scholar
Parkes, J. (1996) Control and restraint training: A study of its effectiveness in a medium secure psychiatric unit. Journal of Forensic Psychiatry. 7(3): 525534.CrossRefGoogle Scholar
Paterson, B. and Leadbetter, D. (1998) Restraint and sudden death from asphyxia. Nursing Times. 94(9): 6264.Google ScholarPubMed
Paton, C., Barnes, T.R., Cavanagh, M.R., Taylor, D., Lelliott, P., POMH-UK project team (2008) High-dose and combination antipsychotic prescribing in acute adult wards in the UK: The challenges posed by p.r.n. prescribing. British Journal of Psychiatry. 192: 435439.CrossRefGoogle ScholarPubMed
Pereira, S., Dawson, P. and Sarsam, M. (2006) The National Survey of PICU and low secure services: 2. Unit characteristics. Journal of Psychiatric Intensive Care. 2: 319.Google Scholar
Price, T.B., David, B. and Otis, D. (2004) The use of restraint and seclusion in different racial groups in an inpatient forensic setting. Journal of the American Academy of Psychiatry and the Law. 32: 163168.Google Scholar
Sailas, E. and Fenton, M. (2000) Seclusion and restraint for people with serious mental illnesses. Cochrane Database of Systematic Reviews. Issue 1. Art. No.: CD001163.CrossRefGoogle ScholarPubMed
SHSA (1993) Report of the Committee of Inquiry into the Death at Broadmoor Hospital of Orville Blackwood and a Review of the Deaths of Two Other Afro-Caribbean Patients. ‘Big, Black and Dangerous?'. London: Special Hospitals Service Authority.Google Scholar
SPSS (2005) SPSS for windows, version 14.0. Lead technologies, Inc.Google Scholar
Steinert, T., Bergbauer, G., Schmid, P., Gebhart, R.P. (2007) Seclusion and restraint in patients with schizophrenia: clinical and biological correlates. Journal of Nervous & Mental Disease. 195(6): 492496.CrossRefGoogle Scholar
Tunde-Ayinmode, M. and Little, J. (2004) Use of seclusion in a psychiatric acute inpatient unit. Australasian Psychiatry. 12(4): 347351.CrossRefGoogle Scholar
Van Citters, A.D., Naidoo, U. and Foti, M.E. (2007) Using a hypothetical scenario to inform psychiatric advance directives. Psychiatric Services. 58(11): 14671471.CrossRefGoogle ScholarPubMed
Veltkamp, E., Nijman, H., Stolker, J., Frigge, K., Dries, P. and Bowers, L. (2008) Patients' preference for seclusion or forced medication in acute psychiatric emergency in the Netherlands. Psychiatric Services. 59(2): 209211.CrossRefGoogle ScholarPubMed
Wynn, R. (2002) Medicate, restrain or seclude? Strategies for dealing with violent and threatening behaviour in a Norwegian university psychiatric hospital. Scandinavian Journal of Caring Sciences. 16(3): 287291.CrossRefGoogle ScholarPubMed