Patient responsiveness as a safewards fidelity indicator: a qualitative interview study on an acute psychiatric in-patient ward.

BACKGROUND: The Safewards model aims to reduce conflict and use of containment on psychiatric wards. To evaluate the implementation of Safewards and understand why it is effective in some settings but not in others, it is important to assess the level of implementation fidelity. To do this, the Safewards Fidelity Checklist (SFC) is often used, which focuses on objective visual observations of interventions but does not include patient responsiveness. The latter is a key indicator of implementation fidelity and includes engagement, relevance, acceptability and usefulness. The aim of the present study was to investigate the fidelity of Safewards implementation on an acute psychiatric ward from the perspective of patient responsiveness. METHOD: The study was conducted on a ward for patients with mainly affective disorders. To assess the general level of fidelity the SFC was used together with a detailed ward walkthrough. Ten patients were interviewed with a focus on patient responsiveness to each of the seven interventions implemented on the ward. Data were analysed using qualitative descriptive analysis. RESULTS: The findings indicate high implementation fidelity, which was reflected in the SFC assessment, walkthrough and patient responsiveness. Patients gave examples of improvements that had happened over time or of the ward being better than other wards. They felt respected, less alone, hopeful and safe. They also described supporting fellow patients and taking responsibility for the ward climate. However, some patients were unfamiliar with a ward where so much communication was expected. Several suggestions were made about improving Safewards. CONCLUSIONS: This study confirms previous research that patient responsiveness is an important factor for achieving fidelity in a prevention programme. The patients' descriptions of the acceptability, relevance and usefulness of the specific interventions reflected to a high degree the objective visual observations made by means of the SFC and ward walkthrough. Patient engagement was demonstrated by several suggestions about how to adapt the interventions. There is potential to obtain valuable input from patients when adapting Safewards in practice. This study also presents many examples of practical work with these interventions and the effects it can have on patients' experiences of care.

A Nursing Process for Shared Decision-Making for Patients with Severe Mental Illness Receiving Treatment Involving Long-Term Coercive Measures: A Modified Grounded Theory Approach.

The use of shared decision-making (SDM) has recently attracted attention for building recovery-oriented therapeutic relationships with patients with severe mental illness (SMI). The purpose of this study was to describe a nursing process for SDM for psychiatric patients with SMI being treated via long-term coercive measures, such as seclusion and physical restraint, in the "seclusion room" of a psychiatric ward. The study used a modified grounded theory approach. The participants were 17 psychiatric nurses. Data were collected via semi-structured interviews. Concepts and categories were generated from verbatim transcripts, and their relationships were illustrated using a diagram and by generating a storyline. The nursing process for SDM was based on sensing the response to triggering stimuli, and the nurse-led preventive measures compensated for the patients' lack of coping skills. Because of the patients' persistent instability in response to certain stimuli, in our process, nurses are involved in creating opportunities for self-understanding and self-selection while also taking proactive preventative measures. Patients' reactions to surrounding stimuli were evaluated by nurses, who then determined whether they (or the patient) should take the lead in terms of decision-making.

Prisoners' Perceptions and Satisfaction with Telepsychiatry Services in Greece and the Effects of Its Use on the Coercion of Mental Healthcare.

BACKGROUND: Prisoners are often associated with mental health and substance use disorders. Coercive measures are widely used in prison settings. The objective of this study was to compare inmates' perceptions and satisfaction with telepsychiatry versus face-to-face consultation and the effects of telepsychiatry on the use of coercive measures. The sample consisted of 100 male inmates from various backgrounds who had experienced both approaches of services (face to face and telepsychiatry). METHOD: The data were obtained through an interview where the individuals completed a Demographic Data Questionnaire, a Participant Satisfaction Questionnaire to assess satisfaction with face-to-face psychiatric services, and a Participant Satisfaction Questionnaire to assess their satisfaction with services offered via telepsychiatry. Additionally, calculations of time spent waiting for a face-to-face psychiatric evaluation and time spent in handcuffs and in confined spaces were made before and after the introduction of telepsychiatry. RESULTS: Statistically significant improvements (all p-values < 0.001) were noted in waiting times, support for relapse prevention, follow up, quality of mental health care, quality of care in the management of psychiatric problems and related medication, behavior of psychiatrists, duration of the assessment, sense of comfort, and confidentiality. Telepsychiatry led to the elimination of time spent in handcuffs and in confined spaces (transport vehicles). CONCLUSION: According to the results of this study, telepsychiatry is an acceptable method of service delivery in correctional facilities and was associated with a reduction of coercive practices.

Handling conflict situations in psychosis inpatient care: Nursing staff experiences of the Interactive Approach model.

WHAT IS KNOWN ON THE SUBJECT?: In inpatient wards, there is a risk that conflicts occur when nursing staff interact with psychotic patients. The Interactive Approach (IA) model is an action-based model, used in psychiatric settings, to manage conflict situations. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The IA model can be used to improve communication between nursing staff and patients in numerous critical situations. Using a structured risk scale to evaluate a conflict can be an effective way to guide action and sort out the different aspects of communication between nursing staff and psychotic patients. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The clarity of an action-based model will help sort out which interventions are most likely to succeed in each conflict situation. The IA model highlights the importance of understanding and strengthening the patient's perspective, being flexible for each individual patient, and providing the patient with clear information about the situation. ABSTRACT: Introduction The Interactive Approach (IA) model is a structured management tool used to improve communication between caregivers and patients in psychiatric care settings. Aim/Question To examine the nursing staff's experiences of the IA model. How do they use the interventions in conflict situations with psychotic patients? Method A sample of nursing staff (n = 11) was recruited from three psychosis inpatient care units. Semi-structured questions covered staff experiences of working with the problem-solving interventions in the IA model. Transcribed data were analysed by qualitative content analysis. Results Three categories were defined: (1) 'To apply a flexible approach' describes how staff tried to adapt to each patient and situation; (2) 'Try to understand the person's inner world' describes the importance of active listening and exploring the patient's concerns; and (3) 'To communicate clearly' relates to experiences of clear communication and the setting up of boundaries. Discussion The risk scale and training in communication skills helped the interaction between staff and patients in conflict situations. Different interventions were used with a focus on maintaining patient alliance. Implications for Practice The findings highlight the importance of educational efforts and practical training, to prevent violence and the use of coercive measures.

Abolition of coercion in mental health services - A European survey of feasibility.

BACKGROUND: In 2019, the Council of Europe agreed to urge member states to take steps toward total abolition of psychiatric coercive measures. AIMS: To test if this aspiration is perceived as realistic and what the alternative would be in the event of a total abolition, we surveyed members of the European FOSTREN network of mental health practitioners and researchers, which is specifically dedicated to exchanging knowledge on reducing psychiatric coercion to its minimum. METHODS: Web-based survey. Categorical responses were analyzed using frequencies, and free text responses were analyzed through thematic analysis. RESULTS: In total, out of 167 invitations to FOSTREN network members, 76 responded to the survey (Response Rate 45.5%). A minority (31%) of participating experts dedicated to the reduction of psychiatric coercive measures believed a total abolition to be an achievable goal. A commonly held belief was that total abolition is not achievable because mental health disorders are difficult to treat and may cause violence, necessitating coercion, and there is a need to protect the involved persons from harm. Those responding that complete abolition is achievable argued that the consequences of coercion outweigh any gains and indicated that use of advance directives are sufficient as alternatives to coercion. CONCLUSION: Of a European group of experts specifically dedicated to the reduction of psychiatric coercion who participated in this questionnaire study, a minority believed a total abolition be an achievable goal. The study adds to the empirical evidence of the feasibility of the aspiration to totally abolish involuntary measures in the mental health services from the perspective of experts.

Mental health patients' preferences regarding restrictive interventions: An integrative review.

WHAT IS KNOWN ON THE SUBJECT?: The use of restrictive interventions is described as a violation of patients' rights and autonomy. It must only be used as a last resort to manage dangerous behaviour, to prevent or reduce the risk of mental health patients harming themselves or others. International mental health policy and legislation agree that when restrictive interventions are applied, the least restrictive alternative should be chosen. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The results are ambiguous, as to which restrictive intervention is preferred over others, but there are tendencies towards the majority preferring observation, with mechanical restraint being the least preferred. To make the experience less intrusive and restrictive, certain factors are preferred, such as a more pleasant and humane seclusion room environment, staff communicating during the application and staff of same gender applying the intervention. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: When applying restrictive interventions, mental health professionals should consider environment, communication and duration factors that influence patient preferences, such as the opportunity to keep some personal items in the seclusion room, or, when using restraint, to communicate the reason and explain what is going to happen. More research is needed to clarify patients' preferences regarding restrictive interventions and their views on which are the least restrictive. Preferably, agreement is needed on standard measures, and global use of the same definition of restrictive interventions. ABSTRACT: INTRODUCTION: The use of restrictive interventions is a violation of patients' rights that causes physical and psychological harm and which is a well-known challenge globally. Mental health law and legislative principles and experts agree that when restrictive interventions are applied, the least restrictive alternative should be used. However, there is no consensus on what is the least restrictive alternative, especially from the patient perspective. AIM: To investigate the literature on mental health patients' preferences regarding restrictive interventions applied during admission to a psychiatric hospital. METHOD: An integrative review informed by the PRISMA statement and thematic analysis were undertaken. RESULTS: There were tendencies towards patients preferring observation and, for the majority, mechanical restraint was the least preferred restrictive intervention. Factors such as environment, communication and duration were found to influence patients' preferences. DISCUSSION: There is a lack of agreement on how best to measure patients' preferences and this complicates the choice of the least restrictive alternative. Nonetheless, our findings show that staff should consider environment, communication and duration when applying restrictive interventions. IMPLICATIONS FOR PRACTICE: More research on restrictive interventions and the least restrictive alternative is warranted, but agreement is needed on standard measures, and a standard global definition of restrictive interventions.

Variation in opinions on coercion use among mental healthcare professionals: a questionnaire study.

INTRODUCTION: Even if coercive measures are widely applied in psychiatry and have numerous well-known drawbacks, there is limited known on the agreement among mental healthcare professionals' opinions on their use. In a questionnaire study using standardized scenarios, we investigated variation in staff opinions on coercion. METHODS: In a web-based survey distributed to staff at three psychiatry hospitals, respondents were asked to consider if and what coercion to use by introducing two hypothetical scenarios involving involuntary psychiatric admission and in-hospital coercion. RESULTS: One hundred thirty-two out of 601 invited staff members responded to the survey (Response Rate = 22%). There was large variation in participating staff members' opinions on how to best manage critical situations and what coercive measures were warranted. In the first scenario, 57% of respondents (n = 76) believed that the patient should be involuntarily admitted to hospital while the remaining respondents believed that the situation should be managed otherwise. Regarding the second scenario, 62% of respondents responded that some in-hospital coercion should be used. The majority of respondents believed that colleagues would behave similarly (60%) or with a tendency towards more coercion use (34%). Male gender, being nursing staff and having less coercion experience predicted being less inclined to choose involuntary hospital admission. CONCLUSION: There is a high degree of variation in coercion use. This study suggests that this variation persists despite staff members being confronted with the same standardized situations. There is a need for evidence-based further guidance to minimize coercion in critical mental healthcare situations.

Ethical Issues in Clinical Decision-Making about Involuntary Psychiatric Treatment: A Scoping Review.

In mental health and psychiatric care, the use of involuntary psychiatric treatment for people with mental disorders is still a central and contentious issue. The main objective of this scoping review was to map and systematize the literature on ethical issues in clinical decision-making about involuntary psychiatric treatment. Five databases (Embase, PsycINFO, CINAHL, Medline, and Scopus) were searched for articles on this topic. Out of a total of 342 articles found, 35 studies from 14 countries were included based on the selection criteria. The articles were analyzed using the inductive content analysis approach. The following main categories were identified: (1) ethical foundations that guide clinical decision-making; (2) criteria for involuntary psychiatric treatment; (3) gaps, barriers, and risks associated with involuntary psychiatric treatment; (4) strategies used to reduce, replace, and improve the negative impact of involuntary treatment; and (5) evidence-based recommendations. Most of the selected articles discuss the logic underlying involuntary treatment of the mentally ill, exploring ethical principles such as autonomy, beneficence, non-maleficence, or justice, as well as how these should be properly balanced. During the process of involuntary psychiatric admission, there was a notable absence of effective communication and a significant power imbalance that disenfranchised those seeking services. This disparity was further intensified by professionals who often use coercive measures without a clear decision-making rationale and by family members who strongly depend on hospital admission. Due to the pluralistic and polarized nature of opinions regarding legal capacity and the complexity and nuance of involuntary admission, further studies should be context-specific and based on co-production and participatory research.

Effects of stricter legislation on coercive measures in child and adolescent psychiatric care: a qualitative interview study with staff.

BACKGROUND: Legislators often want to positively affect psychiatric inpatient care and reduce coercion by a stricter judicial regulation. However, staff experiences and comprehension of such legal changes are largely unknown, yet essential in obtaining the intended outcomes. We examined staff understanding and implementation of a July 1, 2020 legal change in Sweden regarding the use of coercive measures (e.g., restraint, seclusion, and forced medication) in child and adolescent psychiatric inpatient care. METHODS: During 2021, semi-structured interviews were conducted with nine child and adolescent psychiatric inpatient staff (nurses, senior consultants, and head of units). Interviews were transcribed verbatim and analysed using reflexive thematic analysis. We used an implementation outcomes framework to relate data to a wider implementation science context. RESULTS: The legislative change was viewed as both positive and negative by participating staff. They reported mixed levels of preparedness for the legislative change, with substantial challenges during the immediate introduction, including insufficient preparations and lack of clear guidelines. A knowledge hierarchy was evident, affecting various professional roles differently. While the law was positively viewed for its child-centred approach, we found notable distrust in legislators' understanding of the clinical reality, leading to practical difficulties in implementation. Care practices after the legal change varied, with some participants reporting little change in the use of coercive measures, while others noted a shift towards more seclusion and sedative medication usage. The work environment for consultants was described as more challenging due to increased bureaucratic procedures and a heightened pressure for accuracy. CONCLUSIONS: The study highlights the complexities and challenges in implementing legislative changes in psychiatric care, where stricter legislation does not necessarily entail reduced use of coercion.

A country report: impact of COVID-19 lockdowns on involuntary psychiatric treatment in Austria.

BACKGROUND: Coercive measures such as involuntary psychiatric admission are considered a last resort in the treatment of people with psychiatric disorders. So far, numerous factors have been identified that influence their use. However, the link between a pandemic - in particular, restrictions such as lockdowns - and the use of involuntary psychiatric admission is unclear. AIM: To examine the association between COVID-19 lockdowns and involuntary psychiatric admissions in Austria. METHOD: This retrospective exploratory study assessed all involuntary psychiatric admissions and use of mechanical restraint in Austria, except for the federal state of Vorarlberg, between 1 January 2018 and 31 December 2020. Descriptive statistics and regression models were used. RESULTS: During the 3-year study period, 40 012 individuals (45.9% females, mean age 51.3 years) had 66 124 involuntary psychiatric admissions for an average of 10.9 days. Mechanical restraint was used during 33.9% of these admissions. In weeks of nationwide COVID-19 lockdowns (2020 v. 2018/2019), involuntary psychiatric admissions were significantly fewer (odds ratio = 0.93, P = 0.0001) but longer (11.6 (s.d.: 16) v. 10.9 (s.d.: 15.8) days). The likelihood of involuntary admission during lockdowns was associated with year (2020 v. 2018-2019; adjusted odds ratio = 0.92; P = 0.0002) but not with sex (P = 0.814), age (P = 0.310), use of mechanical restraint (P = 0.653) or type of ward (P = 0.843). CONCLUSIONS: Restrictions such as lockdowns affect coercive measures and resulted in fewer but longer involuntary psychiatric admissions during weeks of lockdown in Austria. These results strengthen previous findings that showed the dependence of coercive measures on external factors, highlighting the need to further clarify causality and desired prevention effects when using coercive measures.

The association between the admission to wards with open- vs. closed-door policy and the use of coercive measures.

Introduction: Psychiatric treatment on a ward with open-door policy is associated with reduced numbers of coercive measures. The effect of the door policy of previous stays, however, has not been investigated. Methods: The data set consisted of 22,172 stays by adult inpatients in a psychiatric university hospital between 2010 and 2019. Pairs of consecutive stays were built. The outcome variable was the occurrence of coercive measures during the second stay. Results: Compared to treatments on wards with a closed-door policy at both stays, treatments on wards with an open-door policy at the second stay had smaller odds for coercive measures (OR ranging between 0.09 and 0.33, p < 0.01). In addition, coercive measures were more frequent in treatment histories where patients previously treated on a closed ward were admitted to a ward with an open-door policy and subsequently transferred to a ward with a closed-door policy at the second stay (OR=2.97, p = 0.046). Discussion: Treatment under open-door policy is associated with fewer coercive measures, even in patients with previous experience of closed-door settings. The group of patients who were admitted to a ward with an open-door, then transmitted to a ward with a closed-door policy seem to be prone to experience coercive measures. Clinical strategies to keep these patients in treatment in an open-door setting could further reduce coercive measures.

Models, frameworks and theories in the implementation of programs targeted to reduce formal coercion in mental health settings: a systematic review.

Introduction: Implementation models, frameworks and theories (hereafter tools) provide researchers and clinicians with an approach to understand the processes and mechanisms for the successful implementation of healthcare innovations. Previous research in mental health settings has revealed, that the implementation of coercion reduction programs presents a number of challenges. However, there is a lack of systematized knowledge of whether the advantages of implementation science have been utilized in this field of research. This systematic review aims to gain a better understanding of which tools have been used by studies when implementing programs aiming to reduce formal coercion in mental health settings, and what implementation outcomes they have reported. Methods: A systematic search was conducted using PubMed, CINAHL, PsycINFO, Cochrane, Scopus, and Web of Science. A manual search was used to supplement database searches. Quality appraisal of included studies was undertaken using MMAT-Mixed Methods Appraisal Tool. A descriptive and narrative synthesis was formed based on extracted data. Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed in this review. Results: We identified 5,295 references after duplicates were removed. Four additional references were found with a manual search. In total eight studies reported in nine papers were included in the review. Coercion reduction programs that were implemented included those that were holistic, and/or used professional judgement, staff training and sensory modulation interventions. Eight different implementation tools were identified from the included studies. None of them reported all eight implementation outcomes sought from the papers. The most frequently reported outcomes were acceptability (4/8 studies) and adaptation (3/8). With regards to implementation costs, no data were provided by any of the studies. The quality of the studies was assessed to be overall quite low. Discussion: Systematic implementation tools are seldom used when efforts are being made to embed interventions to reduce coercive measures in routine mental health care. More high-quality studies are needed in the research area that also involves perspectives of service users and carers. In addition, based on our review, it is unclear what the costs and resources are needed to implement complex interventions with the guidance of an implementation tool. Systematic review registration: [Prospero], identifier [CRD42021284959].

Struggling with unnecessary suffering-Registered nurses' experiences of delayed decisions on treatment without consent in forensic psychiatric inpatient care.

Chemical restraints are used in forensic psychiatric inpatient care, however with caution as it can feel like an assault against patients' integrity. When waiting for decisions on treatment without consent, nursing staff are expected to care for patients with severe mental ill-health without the use of medical treatment, often with a feeling of already having tried all other available means. Knowledge about how registered nurses experience such situations is sparse but could contribute to the development of both teamwork and nursing approaches that could mean reduced suffering for patients. The aim of this study was to describe registered nurses' experiences of delayed decisions on treatment without consent in forensic psychiatric inpatient care. Eleven semi-structured interviews were conducted with registered nurses working in forensic psychiatric units in Sweden. Data were analysed through qualitative content analysis. The result showed that experiences of treatment without consent were about striving to protect patients from harm, striving for collaboration during difficult circumstances and striving to do good. This was interpreted as a struggle with unnecessary suffering. For registered nurses to be able to handle such challenging situations and relieve suffering for patients, experience and master-level education in mental health nursing are highlighted. Another aspect that is highlighted is the importance of having consultants familiar with the circumstances at the unit. A method for joint reflection is suggested, to promote an open-minded work culture with a well-functioning decision-making process and ensure that both consultants and nursing staff have support.

Psychometric properties of the Italian version of the staff attitude to coercion scale: an exploratory factor analysis.

Aims: The current study aimed to validate the Italian version of the Staff Attitude to Coercion Scale (SACS), which assesses mental health care staff's attitudes to the use of coercion in treatment. Methods: The original English version of the SACS was translated into Italian, according to the back-translation procedure. Subsequently, it was empirically validated by performing an exploratory factor analysis on a sample of 217 mental health professionals (Mean = 43.40 years, SD = 11.06) recruited form Italian general hospital (acute) psychiatric wards (GHPWs), with at least 1 year of work experience (i.e., inclusion criteria). Results: Results confirmed the three-factor solution of the original version for the Italian version of the SACS, though three items loaded on different factors, compared to the original. The three extracted factors, explained 41% of total variance, and were labeled similarly to the original scale and according to their respective item content, i.e., Factor 1 "Coercion as offending" (items: 3, 13, 14, and 15), Factor 2 "Coercion as care and security" (items: 1, 2, 4, 5, 7, 8, and 9), and Factor 3 "Coercion as treatment" (items: 6, 10, 11, and 12). The internal consistency of the three-factor model of the Italian version of the SACS was assessed through Cronbach's α and yielded acceptable indexes, ranging from 0.64 to 0.77. Conclusion: The present findings suggest that the Italian version of the SACS is a valid and reliable tool that can be used to assess healthcare professionals' attitudes toward coercion.

Strengths Model-Based Nursing Interventions for Inpatients in Psychiatric Inpatient Settings Using a Seclusion Room: A Case Series Study.

The use of coercive measures in psychiatric inpatient settings has been an important issue for many years. Nursing interventions based on a strengths model could enable a reduction in the use of these measures. This study aimed to describe the practice of nursing interventions using a strengths model for psychiatric inpatients who have been in seclusion for a long time. We also constructed a nursing model to minimize coercive measures. The participants were eight inpatients who had been in seclusion for a long time. Nursing interventions based on a strengths model were implemented in collaboration with nurses from six long-term care units in three psychiatric hospitals in Japan. For 4 of the 8 participants, the seclusion time decreased by 20-45%. However, for another 2, it increased by about 23-34%. An average decrease of 9.6% was observed, and the open observation time increased by 1.4 h per day on the seclusion days. When using this model, the nurses considered the effects of stimulating strengths. We believe this approach may promote inpatients' self-insight. Considering the perspective of stimulus adjustment might be useful for maximizing the positive effects of working on strengths.

Who is coercively admitted to psychiatric wards? Epidemiological analysis of inpatient records of involuntary psychiatric admissions to a University General Hospital in Greece for the years 2008-2017.

BACKGROUND: Involuntary psychiatric admissions are a widely used practice despite ethical concerns about coercion. There are particular concerns that vulnerable groups, such as single, unemployed or racial minorities, may be more subjected to such practices. AIM: We aimed to investigate the social patterns of involuntary psychiatric admissions from 2008 to 2017 at University General Hospital in Ioannina, Greece. METHOD: We retrospectively assessed inpatient records from 2008 to 2017 of patients admitted to the Department of Psychiatry of the Ioannina University General Hospital, Northwestern Greece. Alternative patients of alternative years were selected for inclusion; this yielded 332 patients involuntarily admitted, corresponding to 28.5% of total involuntary psychiatric admissions. RESULTS: Over the 10-year period, the overall numbers of annual involuntary psychiatric admissions remained relatively stable, as did the length of hospital stay (mean = 23.8 days). The most common disorder upon admission was schizophrenia spectrum disorders, accounting for approximately two-thirds of all admissions, followed by mood disorders (about 20%). There was evidence that people who lacked social support or experienced financial hardship were more greatly represented among those admitted: 70.2% of admitted patients were single and 64.8% were unemployed. Most patients had been admitted to the psychiatric ward in the past (64.2%). CONCLUSION: Our study indicates potentially worrisome evidence that patients who are in vulnerable positions are at elevated likelihood of being involuntarily admitted to psychiatric wards. Future research is needed to evaluate the socio-demographic patterning of involuntary admissions in other European countries.

Open Doors by Fair Means: a quasi-experimental controlled study on the effects of an open-door policy on acute psychiatric wards.

BACKGROUND: Psychiatric wards treating involuntarily admitted patients are traditionally locked to prevent absconding. However, on the basis of observational evidence, the necessity for locked units in psychiatric hospitals has increasingly been questioned. Updated Mental Health Laws in several Federal States of Germany legitimate involuntary commitment without generally locked doors. METHODS: We examined the effects of an open-door policy in a quasi-experimental, prospective design. For the first time, at each of two locations, two identical wards serving as control and intervention could be compared. After a baseline period of three months, one ward at each location started the 12 month intervention period with the implementation of an open-door policy, while the respective control ward, as before, used open doors only facultatively. Primary outcomes were average opening times of the four wards between 8 a.m. and 8 p.m., and the number of involuntary treatment days with the doors open. Secondary outcomes were adverse events including aggressive incidents, absconding, suicide attempts and coercive measures. RESULTS: Overall, door-opening times increased significantly at both sites´ intervention wards. The number of adverse events did not increase during intervention period. Frequencies of coercive measures decreased in Friedrichshafen and remained unchanged in Tuebingen. In case of the intervention ward in Friedrichshafen, doors were open in up to 91% of all involuntary treatment days, whereas in the control ward, this was only the case in 67% of all involuntary treatment days (p < .001). In case of the intervention ward in Tuebingen, 45% of involuntary treatment days had open doors, compared to 30% in the control ward (p < .001). CONCLUSIONS: It is possible to manage psychiatric wards with open doors without taking inappropriate risks. The extent to which open-door policies are achievable is be dependent on staffing and patient characteristics. Further research is necessary to explore the role of staff attitudes. TRIAL REGISTRATION: Our trial "Open Doors by Fair Means" is retrospectively registered with DRKS ( DRKS00015154 ) on Sept. 10th 2018 and displayed on the public web site. It is searchable via its meta-registry ( http://apps.who.int/trialsearch/ ).

Patient communication ability as predictor of involuntary admission and coercive measures in psychiatric inpatient treatment.

Coercive measures (CM) and involuntary admission to psychiatric treatment can have detrimental consequences for patients. Past research shows that certain clinical, treatment and admission-related characteristics put patients at a higher risk of experiencing CM and involuntary admission. Although of high societal importance, the association between patients' communication ability and CM and involuntary admission has not been subject of past research. To explicitly examine this association the authors conducted a retrospective study using data from patients admitted to psychiatric inpatient treatment via the emergency room at Charité St. Hedwig Hospital, Berlin in 2019. As independent variable, communication ability at admission was recorded (perfect; limited due to language or other reasons; impossible due to language or other reasons) along with possibly confounding variables including demographic, clinical and admission-related details. As dependent variables, involuntary admission and CM were recorded. Multivariate logistic regression analyses were conducted examining the association between communication ability and involuntary admission and CM. In a sample of N = 1556, controlling for potential confounders, limited (OR = 3.08; p = .004) or no communication ability (OR = 4.02; p = .003) due to language barrier or limited (OR = 3.10; p < .001) or no communication ability (OR = 13.71; p < .001) due to other factors were significant predictors for involuntary admission. Limited communication ability due to language barrier (OR = 4.53; p < .001) and limited (OR = 1.58; p = .034) and no communication ability (OR = 3.55; p < .001) due to other factors were significant predictors for CM. These findings show that patients impaired in their communication ability are at higher risk of involuntary admission and CM and highlight the urgency of implementing appropriate interventions facilitating communication during admission and treatment.

Seclusion as a coercive measure in suicidality - daily routine or exception?

BACKGROUND: Coercive measures continue to be an important topic in psychiatry. However, there is no proof of the effectiveness of the use of coercive measures, especially with suicidal people. For many years, attempts have been made to replace such measures with alternative noncoercive intervention options. This paper aims to clarify the situation of coercive measures, more precisely seclusions, in a general psychiatric hospital in Switzerland. It focuses on compulsory measures in patients with suicidal tendencies. METHOD: In this single-centre retrospective cohort study, we used routinely collected medical data and performed qualitative analyses of medical histories to examine whether alternative measures to seclusion had been offered and/or provided to patients who had been secluded solely because of suicidality. Patients were aged 18-65 years and had received inpatient treatment at one of five adult acute care units at a general psychiatric hospital in Switzerland between September 2016 and December 2019. RESULTS: There were 5,935 inpatient treatment cases during the study period. Suicidality was rated as "acute" or "very high" at least once during the hospitalization in 219 (3.7%) cases. Of these, 60 were excluded from further analyses as they involved seclusion, but suicidality was not the exclusive indication for this measure. Coercive seclusion was imposed exclusively due to suicidality in 53 (33.3%) of the remaining 159 cases, whereas 106 (66.7%) cases were not secluded. The rates of seclusion among suicidal patients varied considerably between the hospital wards (13.0% to 55.3%). Suicidal patients with non-Swiss residence status and/or lacking language skills were particularly prone to be secluded. Additionally, alternative interventions were offered and provided significantly more frequently in the nonsecluded patients. CONCLUSIONS: To avoid seclusion due to suicidal tendencies, it is necessary to have a general attitude of avoiding coercive measures at all costs. It is also important for qualified staff to be able to deal with challenging sociodemographic characteristics of patients such as foreign-language, which may require translators and intercultural interpreters.

Relationship Between Time of Admission, Help-Seeking Behavior, and Psychiatric Outcomes: "From Dusk Till Dawn".

Introduction: Day and time of admission influence treatment outcomes and prognosis in several medical specialties; this seems related to resources' ability. It is largely unknown whether this also applies to mental health services. We investigate the relationship between time of admission, patients' demographic and clinical profile, and treatment outcomes. Methods: Demographic and clinical profiles of admitted and discharged patients to a general psychiatric ward between January 1st, 2013 and December 31st, 2020, were analyzed. In addition, we used the last year (i.e., 2020) to monitor rehospitalization. Time of admission was defined as weekdays (working day, weekend) and dayshifts (daytime, dusk, and dawn). Results: During the study period, 12,449 patient admissions occurred. The mean age of the sample was 48.05 ± 20.90 years, with 49.32% (n = 6,140) females. Most admissions (n = 10,542, 84%) occurred on working days. Two-fifths of admissions (39.7%, n = 4,950) were compulsory, with a higher rate outside daytime hours. Patients had slight differences in the clinical profile, resulting from evaluating the different items of the Health of Nation Outcome Scale (HoNOS). Patients admitted on night shifts, weekends, and holidays showed a shorter length of stay; patients compulsorily admitted during daytime (disregarding the day of the week) had a longer length of stay. All patient groups achieved a robust clinical improvement (i.e., an HoNOS score reduction of around 50%), with similar readmission rates. Discussion: The main finding of our study is the relationship between "daytime hours" and fewer compulsory admissions, a result of the interplay between demographics, clinical characteristics, and out-of-clinic service availability (such as ambulatory psychiatric- psychological praxis; day-clinic; home-treatment). The differing clinical profile, in turn, determines differences in treatment selection, with patients admitted after office hours experiencing a higher rate of coercive measures. The shorter length of stay for out-of-office admissions might result from the hospitalization as an intervention. These results should encourage the implementation of outpatient crisis-intervention services, available from dusk till dawn.