Prevalence and variability of restrictive care practice use (physical restraint, seclusion and chemical restraint) in adult mental health inpatient settings: A systematic review and meta-analysis.

BACKGROUND: There is a growing consensus to reduce the use of restrictive care practices in mental health settings to minimise the physical and psychological complications for patients. However, data regarding restrictive care practice use and factors contributing to variations in the proportion estimates has not previously been synthesised. AIMS: This study aimed to synthesise evidence on (1) the pooled proportions of physical restraint, seclusion or chemical restraint in adult mental health inpatients and (2) sources of variability in these proportion estimates. METHODS: Studies were identified from Scopus, MEDLINE, PsycINFO, Web of Science, Embase and CINAHL databases following the PRISMA 2020 guidelines. We conducted a meta-analysis of studies published in English language from 1 January 2010 to 15 August 2022. Binomial data were pooled using a random effect model, with 95% confidence intervals. Meta-regression was also computed to identify factors that may contribute to variations in the proportion estimates. RESULTS: A total of 77 studies were included in this meta-analysis. The pooled prevalence of physical restraint, seclusion and chemical restraint was 14.4%, 15.8% and 25.7%, respectively. Data were heterogeneous across studies (I2 > 99%). Reporting practices and geographical locations contributed to the variability in the reported estimates of restrictive care practices, with studies from Asian countries reporting higher proportions. CONCLUSION: There appear differences between geographical locations in the proportion of restrictive practices in mental health inpatients; however, this is complicated by how these prevalence data have been measured and defined. Consistency in the reporting of restrictive care practices in mental health is required to make valid comparisons between geographical regions, policy settings and practice innovations. RELEVANCE TO CLINICAL PRACTICE: Efforts are needed to develop training programmes and policy changes to ensure consistency in defining and reporting of restrictive care practices in mental health facilities. PATIENT/PUBLIC CONTRIBUTION: This is a systematic review that analysed data from previously published studies, and there was no patient/public contribution in this study. PROTOCOL REGISTRATION: The protocol for this review has been registered to PROSPERO: CRD42022335167.

Healthcare professionals' experiences and perceptions about LGBTIQA+ safety and responsiveness in a mainstream Australian health service: Qualitative findings.

OBJECTIVE: To explore experiences and perspectives of healthcare workers regarding LGBTIQA+ safety and responsiveness. METHODS: Thematic analysis of semi-structured, in-depth interviews, and pre-surveys to collect demographics and knowledge self-rating scales. RESULTS: Of 38 multidisciplinary healthcare staff, 44.7 % identified as LGBTIQA+ and 55.3 % as heterosexual and cisgender allies. Participants discussed experiences, noting strengths and gaps in affirming practice and organisational support, and training and education opportunities. CONCLUSIONS: Health services need to prioritise LGBTIQA+ safety and responsiveness for staff, patients, carers and families. LGBTIQA+ healthcare staff report that they have had experiences of trauma, minority stress, discrimination, homophobia and/or transphobia, and look for visible safe spaces at work and see safer clinical care.

What does consumer and community involvement in health-related education look like? A mixed methods study.

Consumer and community involvement (also referred to as patient and public involvement) in health-related curricula involves actively partnering with people with lived experience of health and social care systems. While health professions education has a long history of interaction with patients or consumers, a shift in the way consumer and community engage in health-related education has created novel opportunities for mutual relationships valuing lived experience expertise and shifting traditional education power relations. Drawing on a mixed methods design, we explored consumer and community involvement practices in the design and delivery of health-related education using the capability, opportunity, motivation and behaviour framework (COM-B). In our results, we describe educator capabilities, opportunities and motivations, including identifying barriers and enablers to consumer and community involvement in health-related education. Educators have varying philosophical reasons and approaches for involving consumers and community. There is a focus on augmenting student learning through inclusion of lived and living experience, and on mutual transformative learning through embedding lived experience and co-creating learning. How these philosophical positionings and motivations shape the degree by which educators involve consumers and community members in health-related curricula is important for further understanding these educational partnerships within universities.

Heteronormative models of health-care delivery: investigating staff knowledge and confidence to meet the needs of LGBTIQ+ people.

Health services internationally are reconsidering whether current service delivery models are inclusive and responsive to lesbian, gay, bisexual, trans* and gender diverse, intersex, and/or queer (LGBTIQ+) identifying individuals. A survey was conducted to establish a baseline needs analysis, as part of an LGBTIQ+ workforce development program, on perceived staff knowledge and confidence in a multi-site public mental health service in Melbourne, Australia. The survey comprising multiple choice, 5-point Likert scale ratings, and short answer sections was administered to mental health staff attending training at their place of work. Workplaces included: community clinics, residential services, acute inpatient services, service development, and research departments. Perceptions of self-confidence and knowledge, and further support needs expressed, were examined through analyzing quantitative and qualitative responses in feedback following the education sessions. The sample comprised 85 respondents; the majority female (66%), with a good representation of staff across age brackets. While the majority of staff identified as heterosexual (68%), LGBTIQ+ individuals were represented. Though 64% of staff surveyed noted that opportunities exist in the workplace to discuss LGBTIQ+ issues, a desire to increase knowledge was expressed by 94% of staff. Staff attitudes, knowledge, confidence, and support needs should be carefully considered at organizational and leadership levels, to ensure health services foster LGBTIQ+ responsive service delivery models and practices.

Challenges in implementing individual placement and support in the Australian mental health service and policy context.

Objective Although Australia's service and policy context differs from that of the US, studies have highlighted potential for individual placement and support (IPS) to support competitive employment outcomes for people with severe and persistent mental illness. The aim of the present study was to explore why the model is not yet widely available. Methods A document analysis was conducted to discern reasons for challenges in implementation of IPS practice principles within the Australian service context. Results The document analysis illustrated that although policy acknowledges the importance of increasing employment rates for people with severe and persistent mental illness, consistent measures, change indicators, direction and time frames are lacking in policy and strategy documentation. Further, IPS principles are not consistently evident in guiding operational documentation that government-funded Disability Employment Services (DES) programs are mandated to adhere to. Conclusions For IPS to be readily implemented, it is necessary for government to offer support to agencies to partner and formal endorsement of the model as a preferred approach in tendering processes. Obligations and processes must be reviewed to ensure that model fidelity is achievable within the Australian Commonwealth policy and service context for programs to achieve competitive employment rates comparable to the most successful international programs. What is known about the topic? The IPS model has been established as the most efficacious approach to support people with severe and persistent mental ill health to gain and sustain employment internationally, yet little is known as to why this model has had very limited uptake in the Australian adult mental health service and policy context. What does this paper add? This paper provides an investigation into the achievability of IPS within DES philosophical and contractual arrangements. What are the implications for practitioners? Mental health practitioners are typically skilled in their understanding of individual or micro-level challenges faced by consumers in achieving vocational goals: working with symptoms, medication side effects, motivation and anxiety. The present study was designed to offer practitioners an increased understanding of service-level factors, because these present considerable challenges to achieving sustained employment. This paper is a call for greater advocacy towards better integration of employment and mental health service delivery in the Australian policy and practice context.

Intervening Early with Family Members during First-Episode Psychosis: An Evaluation of Mental Health Nursing Psychoeducation within an Inpatient Unit.

Provision of psychoeducation to families of service users experiencing a first-episode psychosis has been found to assist with relapse prevention and promoting recovery for service users. Psychoeducation also assists families to reduce isolation and gain relevant information and support. This study aimed to clarify the role inpatient staff can best have with families, targeted to the acute phase and early stage of the illness. Family members were provided an inpatient carer psychoeducation meeting and recruited for a feedback interview 6 months later. Findings suggest that family members require information provision and support during the admission, in addition to beneficial psychoeducation groups offered later in the community.

Early Intervention in Psychosis: Health of the Nation Outcome Scales (HoNOS) Outcomes From a Five-Year Prospective Study.

INTRODUCTION: Over the last two decades, mental health services internationally have shifted towards intervening early in psychosis. The critical period for intervention is estimated to be five-years and many specialised programs target early psychosis. AIM/QUESTION: This prospective cohort study aimed to evaluate five-year outcomes from an early psychosis program (EPP) that adopted an integrated model, providing nursing and multidisciplinary community mental healthcare to clients aged 16-65years, beyond the typical age range of 16-25years. METHOD: We examined one routine outcome measure, the Health of the Nation Outcome Scales (HoNOS) across episodes of care for clients receiving EPP over a 5year period (n=239), comparing these results with HoNOS outcomes in an Australian national dataset for all public mental health clients. RESULTS: HoNOS improvements were highly significant from intake to discharge and from review to discharge for EPP clients, and these compared well with national outcome performance. CONCLUSION: There is potential for mental health nurses and other clinicians to significantly improve client symptoms and functioning, in a model of early psychosis treatment beyond a youth focus.

Who experiences seclusion? An examination of demographics and duration in a public acute inpatient mental health service.

Restrictive interventions such as seclusion may occur during an acute mental health crisis. Such interventions are experienced by people as traumatic and counter to recovery. The current study aimed to investigate the use of seclusion and who was secluded amongst patients presenting with psychotic symptomology. All acute inpatient admissions were examined across a 12-month period January-December 2013. Electronic and paper records were accessed and audited for all 655 admissions. There were 91 admissions that included a seclusion and 200 seclusion events. There were 79 unique patients who experienced seclusion. For those experiencing seclusion: two-thirds were male, 49% were either homeless or had no fixed abode, 32% received case management in the community prior to their inpatient stay, and 56% were unemployed or not in the workforce. The median and mode duration of seclusion was 4 h. By understanding seclusion interventions better, changes can be made to enhance practice. This descriptive research into seclusion has clarified the demographics of who is most likely to experience seclusion, for how long, and the implications for reducing restrictive interventions. How the social work role could contribute to reforms to protect and enhance the rights and well-being of marginalized members of our communities, at their most vulnerable, is considered.

First episode psychosis in an adult area mental health service-a closer look at early and late-onset first episode psychosis.

OBJECTIVES: To review the characteristics of all patients presenting with a first episode of psychosis between the ages of 16 and 65 years to an adult area mental health service. METHODS: The early psychosis programme at St Vincent's Hospital Melbourne treats all patients presenting in the early stages of psychosis between the ages of 16 and 65 years. A database was developed to capture the demographic and diagnostic characteristics of the group. The characteristics of those with an onset under 26 years were compared with those with a later onset. RESULTS: A large proportion (55%) of those presenting with first episode psychosis presented after the age of 25 years. There were a higher number of cases of depression with psychotic features in the older onset patients (notably so for those over 40) and a trend towards greater metabolic morbidity. DISCUSSION: Older patients presenting with a first episode of psychosis are relatively understudied but appear to have certain distinguishing qualities. Understanding the needs of these patients is important in tailoring optimal treatment packages and service responses.

Workforce Perspectives of Sustaining the Utilisation of a Harm Reduction Instrument in a Mental Health Residential Setting.

PURPOSE: This exploratory study investigated worker experiences of utilising the Before During After (BDA) harm reduction instrument to engage well with service users in a residential mental health service setting. Stakeholder interviews were conducted with a purposive sample of two senior nurses and one senior allied health staff at the study site to explore the impacts of BDA implementation on their work after 3 years of its use. A thematic analysis was conducted, including two-level coding. Five major themes were discussed. Of particular interest, and the focus of this paper, are the themes of effect on service users and effect on staff. The study found improved engagement between staff and service users, reduced stigma and more holistic care that was collaborative. In regard to staff, it was found that staff knowledge and confidence increased in addressing harm reduction issues with consumers and this was sustained over 3 years. Use of the BDA clinical instrument and package was reported to enhance worker engagement, knowledge and confidence in dual diagnosis work with service users.

Implementing the Strengths Model of case management: group supervision fidelity outcomes.

To evaluate group supervision implementation fidelity in the Strengths Model of case management within one adult mental health service. A fidelity audit was undertaken to analyse data across three service settings-residential and community-during the initial three months, utilising instruments developed by Rapp and Goscha (The Strengths Model: Case management with people with psychiatric disabilities, vol 2. Oxford University Press, New York, 2006). Very high fidelity for group supervision was achieved for group interaction (74.8%), client work (77%) and by case managers (90%). A standardised approach to group supervision process and documentation greatly supported fidelity in implementation. The Rapp and Goscha tools had utility as both learning aids and audit instruments.

Echocardiographic monitoring for clozapine cardiac toxicity: lessons from real-world experience.

OBJECTIVE: We aimed to identify the baseline prevalence of cardiac dysfunction in patients commencing clozapine, assess adherence with echocardiographic monitoring recommendations, and evaluate the utility and cost of echocardiographic monitoring for the development of clozapine-associated myocarditis and cardiomyopathy. METHODS: A retrospective longitudinal cohort study was undertaken of 159 consecutive patients from a major tertiary centre commencing clozapine in the period January 2002 to July 2009. RESULTS: Some 73% of patients had a baseline study, and 11% had a six-month follow-up study. Nine patients had abnormal left ventricular function at baseline. Myocarditis was identified in three patients, with all cases occurring within the first month of treatment and suspected on clinical grounds before an echocardiogram was performed. One case of possible cardiomyopathy was identified. The cost of echocardiographic screening in the first year of treatment was estimated at $AUD 209,356 per case of cardiomyopathy detected. CONCLUSION: The prevalence of cardiac dysfunction in patients commencing clozapine is high, and there are challenges in adhering with the recommended protocol for monitoring. Routine echocardiography is not useful in the detection of clozapine-associated myocarditis. Although cardiomyopathy may be identified, it is rare and associated with significant cost. Recommendations for routine echocardiographic monitoring should be re-examined.

A social work contribution to suicide prevention through assertive brief psychotherapy and community linkage: use of the Manchester Short Assessment of Quality of Life (MANSA).

There is a striking absence of literature articulating and evaluating clinical social work contributions to suicide prevention, despite considerable practice in this important field. This article reports on a model of assertive brief psychotherapeutic intervention and facilitated linkage to community services utilized in a prospective cohort study of emergency department suicide attempt aftercare. A key outcome measure, the Manchester Short Assessment of Quality of Life (MANSA), was used with 65 patients to assess psychosocial domains at initial presentation, 4-weeks, 3-months, and 6-months. There were significant improvements in the domains of work, finance, leisure, social life, living situation, personal safety and health by 3 months. There were highly significant correlations between psychosocial improvements and improved depression scores.

Spiritual Diversity in Personal Recovery from Mental Health Challenges: A Qualitative Study from Chinese-Australian Service Users' Perspectives.

Spiritual diversity and the positive role of spirituality in personal recovery have received growing attention in mental health literature. However, the spiritual experiences and views of service users from cultural communities, particularly the Chinese community, are understudied in Australia. This research explores Chinese service users' spiritual identities and their views and perspectives on the roles of spirituality in their mental health recovery and attempts to provide inspiration for practitioners to engage with service users' spirituality in non-clinical mental health practice. A qualitative exploratory approach guided this study. Semi-structured interviews were employed with four Chinese participants with spiritual identities, who were recruited through the community Psychosocial Support Service in Victoria. The template analysis method supported the data analysis. The results indicate that spirituality has a positive impact on the mental health recovery of participants, primarily through coping, self-regulatory, and social support mechanisms. The findings also present that Chinese service users' understanding and approaches to spirituality are shaped by both original and Australian Cultures. These findings suggest that practitioners should provide a creative understanding and cultural awareness when discussing with service users their spiritual identities, perspectives, and spirituality in the wider context. The research fills a gap in the spiritual views and perspectives of service users accessing a non-clinical mental health service from the Chinese community.

Mental Health Clinician Attitudes about Service User and Family Agency and Involvement in Recovery-Oriented Practice.

BACKGROUND: Recovery-oriented practice (ROP) is a framework focusing on recovery through hope, choice, and meaning, to live with or without enduring symptoms and challenges. AIMS: To examine clinicians' attitudes about the involvement of service users and family or supporters in ROP. METHODS: A bespoke Qualtrics survey obtained views of mental health clinicians working in an Australian public mental health service about service user and family involvement in ROP, using a five-point Likert scale of agreement and free-text responses. Data were analysed with descriptive statistics and content analysis methods. RESULTS: Two hundred and three clinicians completed the survey. Most (79%) clinicians agreed with the statement that service users want clinicians to use ROP principles, and the majority (63%) also 'strongly believed' that ROP made a difference to service users' mental health outcomes. Only 15% 'strongly agreed' and 57% somewhat agreed with the statement that service users know what treatment is best for them, and only 20% of clinicians 'strongly agreed' that supporters of service users believed in and wanted ROP for their family member or friend. FUTURE DIRECTIONS: This study adds to the literature on clinicians' views about ROP and shows that although clinicians are supportive of ROP, they also express substantial ambivalence about whether service users and families know what treatment is best. For ROP implementation to be successful, workforce training needs to support clinicians to reflect on these views with service users and families, and to encourage supported decision making. Future studies should focus on changes in clinicians' views and practice post ROP training.

Staff Perspectives in Mental Health Research Regarding Restrictive Interventions: An Australian Scoping Review and Thematic Analysis.

Service users and their families have raised concerns about safety in current acute mental health service delivery. Restrictive interventions are routinely used across mental health settings despite increasing awareness of the negative impacts. Underfunding and risk-averse management practices are implicated as key challenges. Utilizing a scoping review and thematic analysis method, this review explored the existing literature of mental health staff perspectives across various settings (including psychiatric wards and emergency departments), focusing on their experience of restrictive interventions. Four themes were developed: 1. Safety (both staff and patient); 2. Barriers to staff reducing their restrictive interventions; 3. Strength in current practice; 4. Recommendations for change. Key gaps in the literature were the limited perspectives of emergency and crisis clinicians (despite these areas being settings where restrictive interventions are utilized) and limited perspectives from allied health disciplines (despite their employment as clinicians in these settings). It also noted a divide between staff and patient safety, as though these concerns are mutually exclusive rather than cooccurring, which is the experienced reality. Advocacy bodies, governments and the media are calling for a reduction in restrictive interventions in crisis settings. This research synthesis proposes that, to achieve this, clinical staff must be involved in the process and their perspectives actively sought and drawn upon to enable reform.

Employment interventions to assist people who experience borderline personality disorder: A scoping review.

BACKGROUND: Employment is an important social determinant of health and is associated with positive health outcomes. However, individuals who have been diagnosed with borderline personality disorder (BPD) are significantly underrepresented in the workforce. Whilst there is an array of evidence based therapeutic interventions, there remains a gap in knowledge regarding the most effective ways to enhance employment outcomes for people with a diagnosis of BPD. AIM: To explore employment interventions for people with BPD, map the available evidence and identify key concepts and knowledge gaps. METHODS: A scoping review was conducted to identify and map the relevant literature. Findings were summarised using a narrative approach. Consultation was provided by a reference group including peer support workers with lived experience of BPD and mental health clinicians. RESULTS: Seven articles met the inclusion criteria, including non-randomised and case study/series designs and a randomised controlled trial protocol, with participant numbers generally low. All programmes combined a psychotherapeutic component with work related goals; however, there were notable differences in relation to the conceptual/theoretical approach of the psychotherapeutic component and delivery of the work-related components. Barriers and enablers to programme participation and success are explored. CONCLUSIONS: This review provides important insights into the characteristics of vocational rehabilitation interventions for people diagnosed with BPD. The findings will inform the co-production of approaches to support people with BPD to engage in employment.

Suicide attempt presentations at the emergency department: outcomes from a pilot study examining precipitating factors in deliberate self-harm and issues in primary care physician management.

The aim of this study was to examine the psychosocial precipitating factors of people presenting to the emergency department (ED) due to attempted suicide. Demographic, diagnostic and service use data were collected for a 6-week period. All patients were referred for primary care physician (PCP) management, with a sample followed up for secondary analysis of precipitants to self-harm and follow-up outcomes. Results of the study showed that key psychosocial stressors that triggered suicidality were relationship issues and recent unemployment, with depression present in 92% of cases. While 83% of patients followed attended their first PCP appointment, 50% discontinued by 3 months. The conclusion of this study is that psychosocial crises and depression are key factors in suicide attempts. Assertive crisis intervention, facilitated linkage to community services, and greater monitoring are recommended.

Using photovoice to explore women's experiences of a women-only prevention and recovery care service in Australia.

Women should be able to access mental health services that are safe, free from harassment and abuse. Yet, research indicates that women experiencing mental health issues are often not safe in mixed gender environments, and especially in inpatient settings. This qualitative study draws on a photo-elicitation method ('photovoice') and semi-structured interviews to explore women's experiences of a sub-acute women-only prevention and recovery care (PARC) service in Australia. Twelve women experiencing mental health issues were recruited via an aftercare peer support group for recent service participants. The women took photographs guided by the central question: 'What were your experiences of a women-only prevention and recovery care service?' They then shared these photographs with the researchers and each other, and described them in detail. Four key themes were identified by thematic analysis of the photovoice visual and narrative data: (a) Only women can understand what women go through; (b) I feel safer with no men around due to my history of trauma; (c) This environment feels safe, making it easier to talk and (d) Staff are accessible and make time for me to talk about difficult topics. Woven throughout the women's narratives was the expressed desire to feel safe and supported during the process of recovering. Aspects of service delivery that contributed to these feelings and facilitated shared support were also valued in this setting. These findings indicate that access to women-only services and peer support are not only valued by women experiencing mental health issues, but need to be more widely available to support their recovery. They also underline the importance of a trauma-informed approach for improving the gender sensitivity of services.

Safety for women when accessing mental health services: a scoping review of the link between safety and recovery.

ObjectiveA sense of safety and recovery from mental health issues seem to be interrelated concepts but, to date, there has been no review of studies exploring the links between safety and recovery for women accessing mental health programs. This review aimed to identify current knowledge and knowledge gaps regarding the experiences of women and their personal safety when accessing mixed-gender and women's mental health programs.MethodsA scoping review methodology was used. Four electronic databases (Medline, PsycINFO, AMED, and CINAHL) were searched, covering the period from January 2000 to December 2019, to identify relevant peer-reviewed articles, which were screened for inclusion. Key search terms included ('women' or 'female' or 'gender') and ('recovery' and 'mental health programs') or ('community mental health' or 'community mental health centres/or community mental health centre') and 'safety'.ResultsTwelve studies were identified, 10 of which were from English-speaking countries (five from the UK, three from Australia, two from the US) and two from European countries, indicating there is limited literature directly relevant to women with mental health issues and their personal safety while using mental health services. Safety from assault and harassment and finding safe and supportive connections were commonly reported as crucial to the process of recovery for the women with mental health issues across these studies.ConclusionsBased on the identified knowledge gaps, this paper advances the argument for more research to inform gender-specific service provision.What is known about the topic?Service guidelines identify the need for gender-sensitive practices in mental health services, yet women continue to report experiences of sexual or other forms of harassment while in acute and subacute mental health programs.What does this paper add?This study identified the current knowledge regarding the experiences of women when accessing mental health programs. In particular, a sense of feeling safe in services was crucial to the process of recovery for women with mental health issues.What are the implications for practitioners?This study contributes to the body of knowledge informing health professionals who work within these mental health programs and highlights the need to meet women's needs to feel safe when accessing services.