Healthcare staff's experiences of using manual physical restraint: A meta-synthesis review.

Manual restraint is a hands-on type of physical restraint used to prevent harm to service users and staff, and to administer necessary treatments. This article reports on a review and meta-synthesis of the qualitative literature on healthcare staff's experiences of using manual restraint. Three electronic databases (CINAHL Complete, MEDLINE, and PsycINFO) were systematically searched, and 19 studies were included. Thematic synthesis was used to synthesize the findings. The Critical Appraisal Skills Programme (CASP) checklist was used to appraise study quality. The synthesis generated one overarching interpretive theme, "unpleasant but necessary," and five subthemes: "maintaining safety triumphs all," "emotional distress," "significance of coping," "feeling conflicted," and "depletion." Seven studies indicated that, from staff perspectives, manual restraint was not always used as a last resort. Healthcare staff experience manual restraint as a psychologically and physically unpleasant practice, yet paradoxically deem its use to be sometimes necessary to keep themselves and service users safe from harm. The findings indicate a need for healthcare staff support, post-restraint debriefing meetings with service users, and the implementation of manual restraint minimization programs in healthcare settings.

Restraint minimisation in mental health care: legitimate or illegitimate force? An ethnographic study.

Coercive practices, such as physical restraint, are used globally to respond to violent, aggressive and other behaviours displayed by mental health service users.1 A number of approaches have been designed to aid staff working within services to minimise the use of restraint and other restrictive practices. One such approach, the 'REsTRAIN Yourself' (RYS) initiative, has been evaluated in the UK. Rapid ethnography was used to explore the aspects of organisational culture and staff behaviour exhibited by teams of staff working within 14 acute admission mental health wards in the North West region of the English NHS. Findings comprise four core themes of space and place; legitimation; meaningful activity; and, therapeutic engagement that represent characteristics of daily life on the wards before and after implementation of the RYS intervention. Tensions between staff commitments to therapeutic relations and constraining factors were revealed in demarcations of ward space and limitations on availability of meaningful activities. The physical, relational and discursive means by which ward spaces are segregated prompts attention to the observed materialities of routine care. Legitimation was identified as a crucial discursive practice in the context of staff reliance upon coercion. Trauma-informed care represents a potentially alternative legitimacy.

It's the talk: a study of involvement initiatives in secure mental health settings.

BACKGROUND: A study of involvement initiatives within secure mental health services across one UK region, where these have been organized to reflect alliances between staff and service users. There is little previous relevant international research, but constraints upon effective involvement have been noted. OBJECTIVE: To explore and evaluate involvement initiatives in secure mental health settings. DESIGN: A case study design with thematic analysis of qualitative interviews and focus groups. SETTING AND PARTICIPANTS: Data collection was carried out between October 2011 and February 2012 with 139 staff and service users drawn from a variety of secure mental health settings. FINDINGS: Our analysis offers four broad themes, titled: safety and security first?; bringing it all back home; it picks you up; it's the talk. The quality of dialogue between staff and services users was deemed of prime importance. Features of secure environments could constrain communication, and the best examples of empowerment took place in non-secure settings. DISCUSSION: Key aspects of communication and setting sustain involvement. These features are discussed with reference to Jurgen Habermas's work on communicative action and deliberative democracy. CONCLUSIONS: Involvement initiatives with service users resident in secure hospitals can be organized to good effect and the active role of commissioners is crucial. Positive outcomes are optimized when care is taken over the social space where involvement takes place and the process of involvement is appreciated by participants. Concerns over risk management are influential in staff support. This is germane to innovative thinking about practice and policy in this field.

[Content validation of the questionnaire "The Management of Aggression in People with Dementia Attitude Questionnaire German Version" (MAPDAQ-G)]. / Inhaltsvalidierung des Fragebogens «The Management of Aggression in People with Dementia Attitude Questionnaire German Version¼ (MAPDAQ-G).

BACKGROUND: Dementia is one of the most common diseases of aging and leads to an increased need for care. Caregivers' attitudes about aggression can influence their interaction with people with dementia. To examine this further, "The Management of Aggression in People with Dementia Attitude Questionnaire" (MAPDAQ) was developed for use in nursing homes in the United Kingdom. In Switzerland, the MAPDAQ has been translated into a German Version (MAPDAQ-G), but not yet tested for its validity and reliability. AIM: Therefore the present study examined the content and face validity, comprehensibility and interpretability of MAPDAQ-G in a Swiss context. METHODS: The review was based on expert surveys and interviews with caregivers in nursing homes and psychiatric hospitals. RESULTS: According to experts, the optimised MAPDAQ-G is comprehensive (88 %) and shows good content validity (I-CVI = 0,6 ­ 0,1; S-CVI-Ave = 0,88). 15 items have been adapted and further validated by 16 nurses. Finally, apart from two items, the MAPDAQ-G is understood by nurses and can be interpreted consistently. CONCLUSIONS: A questionnaire of this sort allows nurses to reflect in practice upon their own attitude with regard to the management of aggression in people with dementia and to influence the quality of care. The MAPDAQ-G should be statistically tested for validity and reliability using a larger sample.

Multinational experiences in reducing and preventing the use of restraint and seclusion.

Restraint and seclusion (R/S) have been used in many countries and across service sectors for centuries. With the recent and increasing recognition of the harm associated with these procedures, efforts have been made to reduce and prevent R/S. Following a scathing media exposé in 1998 and congressional scrutiny, the United States began a national effort to reduce and prevent R/S use. With federal impetus and funding, an evidence-based practice, the Six Core Strategies to Prevent Conflict, Violence and the Use of Seclusion and Restraint, was developed. This model was widely and successfully implemented in a number of U.S. states and is being adopted by other countries, including Finland, Australia, and the United Kingdom. Recently, the first cluster randomized controlled study of the Six Core Strategies in Finland provided the first evidence-based data of the safety and effectiveness of a coercion prevention methodology. Preliminary findings of some of the international efforts are discussed. Reduction in R/S use and other positive outcomes are also reported.

Classroom-based and distance learning education and training courses in end-of-life care for health and social care staff: a systematic review.

BACKGROUND: Staff from a range of health and social care professions report deficits in their knowledge and skills when providing end-of-life and palliative care, and education and training has been advocated at a range of levels. AIMS: To review the literature related to classroom-based and distance learning education and training initiatives for health and social care staff in end-of-life and palliative care, in terms of their target audience, extent, modes of delivery, content and teaching and learning strategies, and to identify the most effective educational strategies for enhancing care. DESIGN: A systematic review of the literature evaluating classroom-based and distance learning education and training courses for health and social care staff in end-of-life and palliative care. DATA SOURCES: Online databases CINAHL, MEDLINE, EMBASE and PSYCHINFO between January 2000 and July 2010. Studies were selected that discussed specific education and training initiatives and included pre-and post-test evaluation of participants' learning. RESULTS: 30 studies met eligibility criteria. The majority reported successful outcomes, though there were some exceptions. Level of prior experience and availability of practice reinforcement influenced learning. Participative and interactive learning strategies were predominantly used along with discussion of case scenarios. Multi-professional learning was infrequently reported and service user and carer input to curriculum development and delivery was reported in only one study. CONCLUSIONS: Classroom-based education and training is useful for enhancing professionals' skills and perceived preparedness for delivering end-of-life care but should be reinforced by actual practice experience.

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].

An Evaluation of the Implementation of a "No Force First" Informed Organisational Guide to Reduce Physical Restraint in Mental Health and Learning Disability Inpatient Settings in the UK.

BACKGROUND: The use of physical restraint on vulnerable people with learning disabilities and mental health problems is one of the most controversial and criticised forms of restrictive practice. This paper reports on the implementation of an organisational approach called "No Force First" within a large mental health organisation in England, UK. The aim was to investigate changes in violence/aggression, harm, and physical restraint following implementation. METHODS: The study used a pretest-posttest quasi-experimental design. Recorded incidents of violence/aggression from 44 inpatient mental health and learning disabilities (including forensic) wards were included (n = 13,599). Two study groups were created for comparison: the "intervention" group comprising all incidents on these wards during the 24 months post-implementation (2018-2019) (n = 6,551) and the "control" group comprising all incidents in the 24 months preceding implementation (2015-2016) (n = 7,048). Incidents recorded during implementation (i.e., 2017) were excluded (n = 3,705). Incidence rate ratios (IRR) were calculated with 95% confidence intervals (95% CI). Multivariate regression models using generalised estimating equations were performed to estimate unadjusted and adjusted prevalence ratios (aPR) of physical restraint and harm, using type of wards, incident, and violence/aggression as key covariates. RESULTS: A significant 17% reduction in incidence of physical restraint was observed [IRR = 0.83, 95% CI 0.77-0.88, p < 0.0001]. Significant reductions in rates of harm sustained and aggression/violence were also observed, but not concerning the use of medication during restraint. The prevalence of physical restraint was significantly higher in inpatients on forensic learning disability wards than those on forensic mental health wards both pre- (aPR = 4.26, 95% CI 2.91-6.23) and post-intervention (aPR = 9.09, 95% CI 5.09-16.23), when controlling for type of incident and type of violence/aggression. Physical assault was a significantly more prevalent risk factor of restraint use than other forms of violence/aggression, especially that directed to staff (not to other patients). CONCLUSIONS: This is a key study reporting the positive impact that organisational models and guides such as "No Force First" can have on equipping staff to focus more on primary and secondary prevention as opposed to tertiary coercive practices such as restraint in mental health and learning disabilities settings.

Mapping review of interventions to reduce the use of restrictive practices in children and young people's institutional settings: The CONTRAST study.

Restrictive practices are often used harmfully with children in institutional settings. Interventions to reduce their use do not appear to have been mapped systematically. Using environmental scanning, we conducted a broad-scope mapping review of English language academic databases, websites and social media, using systematic methods. Included records (N = 121) were mostly from the United States and contained details of 82 different interventions. Children's participation was limited. Reporting quality was inconsistent, which undermined claims of effectiveness. Overall, despite a multitude of interventions, evidence is limited. Leaders should consider the evidence, including children's perspectives, before introducing poorly understood interventions into children's settings.

Approaches used to prevent and reduce the use of restrictive practices on adults with learning disabilities: Protocol for a realist review.

INTRODUCTION: The use of restrictive practices has significant adverse effects on the individual, care providers and organisations. This review will describe how, why, for whom, and in what circumstances approaches used by healthcare organisations work to prevent and reduce the use of restrictive practices on adults with learning disabilities. METHODS AND ANALYSIS: Evidence from the literature will be synthesised using a realist review approach - an interpretative, theory-driven approach to understand how complex healthcare approaches work in reducing the use of restrictive practices in these settings. In step 1, existing theories will be located to explore what approaches work by consulting with key topic experts, holding consultation workshops with healthcare professionals, academics, and experts by experience, and performing an informal search to help develop an initial programme theory. A systematic search will be performed in the second step in electronic databases. Further searches will be performed iteratively to test particular subcomponents of the initial programme theory, which will also include the use of the CLUSTER approach. Evidence judged as relevant and rigorous will be used to test the initial programme theory. In step three, data will be extracted and coded inductively and deductively. The final step will involve using a realist logic of analysis to refine the initial programme theory in light of evidence. This will then provide a basis to describe and explain what key approaches work, why, how and in what circumstances in preventing and reducing the use of restrictive practices in adults with learning disabilities in healthcare settings. RESULTS: Findings will be used to provide recommendations for practice and policymaking. REGISTRATION: In accordance with the guidelines, this realist review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 4th December 2019 (CRD42019158432).

Should nurses restrain violent and aggressive patients?

Violent and aggressive behaviour towards nurses is common, especially in mental health settings. This article explores the value and safety of existing approaches to dealing with violence and aggression, including the use of physical restraint and medication. It highlights the need for greater preventive and participatory measures, and the use of less reactive strategies, such as advance directives.

Taser use on individuals experiencing mental distress: An integrative literature review.

WHAT IS KNOWN ABOUT THE SUBJECT?: People experiencing mental distress have a high rate of contact with police in community crisis events. Police use a continuum of responses when managing situations involving agitation, aggression and behavioural problems. People experiencing mental distress have been subjected to Tasers as part of the police response. Following a number of deaths and numerous reports of injuries, concerns have been raised about the safety of Tasers. WHAT THIS PAPER ADDS?: Police use of Tasers in mental health crises is relatively common. Tasers are used in a range of settings including public places, private residences and healthcare facilities. People experiencing mental distress may be subjected to more use of Tasers than the general population. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health professionals need to work with police towards greater understanding of the needs of people experiencing mental distress and to promote the use of non-coercive interventions in mental health crisis events. Mental health researchers need to explore the qualitative experiences of people who are Tasered, to provide an evidence base for Taser use with people experiencing mental distress. ABSTRACT: Introduction Conducted electrical weapons, or "Tasers," are currently used by over 15,000 law enforcement and military agencies worldwide. There are concerns regarding the effectiveness, potential for harm and overuse with people experiencing mental distress. Aim To explore the literature about police use of Tasers with people experiencing mental distress. Method An integrative review was undertaken, and qualitative and quantitative analytical approaches were used. Results Thirty-one studies were included. Of all recorded usage, overall prevalence of Taser use on people experiencing mental distress was 28%. This population appears to experience higher Taser usage than the general population. Discussion There are substantial gaps in the research literature particularly with respect to the decision-making processes involved in deploying Tasers on this population and the physical and psychological consequences of Taser use in this context. Implications for practice Police use of Tasers in mental health crises is relatively common and occurs in a variety of environments including mental health settings. Mental health professionals need to work with police towards greater understanding of the needs of people with mental illness and to promote the use of non-coercive interventions in mental health crisis events.

'Care co-ordinator in my pocket': a feasibility study of mobile assessment and therapy for psychosis (TechCare).

OBJECTIVES: The aim of the project was to examine the acceptability and feasibility of a mobile phone application-based intervention 'TechCare', for individuals with psychosis in the North West of England. The main objectives were to determine whether appropriate individuals could be identified and recruited to the study and whether the TechCare App would be an acceptable intervention for individuals with psychosis. METHODS: This was a mixed methods feasibility study, consisting of a test-run and feasibility evaluation of the TechCare App intervention. SETTING: Early Intervention Services (EIS) for psychosis, within an NHS Trust in the North West of England. PARTICIPANTS: Sixteen participants (test-run n=4, feasibility study n=12) aged between 18 and 65 years recruited from the East, Central and North Lancashire EIS. INTERVENTION: A 6-week intervention, with the TechCare App assessing participants' symptoms and responses in real-time and providing a personalised-guided self-help-based psychological intervention based on the principles of Cognitive Behaviorual Therapy (CBT). RESULTS: A total of 83.33% (n=10) of participants completed the 6-week feasibility study, with 70% of completers achieving the set compliance threshold of ≥33% engagement with the TechCare App system. Analysis of the qualitative data suggested that participants held the view that the TechCare was both an acceptable and feasible means of delivering interventions in real-time. CONCLUSION: Innovative digital clinical technologies, such as the TechCare App, have the potential to increase access to psychological interventions, reduce health inequality and promote self-management with a real-time intervention, through enabling access to mental health resources in a stigma-free, evidence-based and time-independent manner. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT02439619.

A structured observation of the interaction between nurses and patients during the administration of medication in an acute mental health unit.

AIMS: This aims of this study are to describe current practice in the administration of medication in an acute psychiatric unit and explore factors that influence nurses' decisions regarding the administration of medication during 'rounds'. Background. Medication 'rounds' form part of the ward routine in many inpatient mental health settings. Nurses make several clinical decisions about administrating medication; yet, concerns have been raised about the poor assessment of patients' needs and the quality of the information exchanged. DESIGN: A structured non-participant observational design was used for this research. METHOD: This study involved the observation of 20 medication 'rounds' over three months. The Ward Administration of Medication Schedule was used to report on the interactions between nurses and patients and aspects of their communication during each round. RESULTS: From the rounds observed nurses appeared adept at communicating a positive interpersonal style but less so in demonstrating skills portraying collaboration and information giving. For example whilst nurses communicated warmth in 97% of cases, using non-verbal behaviours such as good eye contact, the provision of information was only initiated in 46% of cases. Enquiries regarding the patient's general health and medication taking (35% and 17% respectively) were less commonly observed. Verbal consent was sought in only 25% of cases. Procedural matters were adhered to overall. CONCLUSIONS: Findings suggest limited collaboration between nurses and patients and the poor monitoring of health status and medication effects. Information exchange could be improved; however, this may be related to medication procedures that make it difficult to explore sensitive information with patients, rather than nursing skills and behaviour. RELEVANCE TO CLINICAL PRACTICE: The Ward Administration of Medication Schedule can be used as a clinical or educational tool in the administration of medication. In both instances, it may be self-administered and used to reflect on personal skills or employed as an observational tool during peer review and audit.

A hermeneutic phenomenological exploration of 'last resort' in the use of restraint.

Restraining patients is a practice that dates back at least three centuries. In recent years, there has been a mandate and advocacy in various countries for organizations to shift towards the minimization of restraint, whereby its use is only as a 'last resort'. There is growing evidence internationally indicating the negative impact of the use of restraint. However, to date there is no research specifically focusing on trying to understand the concept of 'last resort'. Further insights to explore this concept among mental health nurses are therefore warranted. The empirical research comprised a hermeneutic phenomenological study. By recruiting and interviewing thirteen mental health nurses from across Canada who had experiences of restraint use, the research aimed to generate a deeper understanding of the meanings and lived experiences of the concept of 'last resort'. Data were collected through fifteen in-depth interviews. Data analysis was undertaken through a hermeneutic phenomenological framework based on van Manen's approach and Heideggerian philosophy. Five Heideggerian concepts were used to illuminate 'last resort' in restraint use by mental health nurses - temporality, inauthenticity, thrownness, leaping in and leaping ahead, and mood (fear). Key findings highlight the influence of nurses' past experiences, how nursing staff adopt a collective (rather than individual) approach, and the dependency on knowledge and skills of others in using restraint as a 'last resort'. Overall, the lived experience of 'last resort' is comprised of many elements. This study provides insights and an initial understanding, which is hoped to advance the field of restraint minimization.

"Catching your tail and firefighting": The impact of staffing levels on restraint minimization efforts.

WHAT IS KNOWN ON THE SUBJECT?: Mental health nursing in the UK and other countries faces an acute workforce crisis. Safe staffing levels are called for, and in some jurisdictions have been legislated for. The evidence base linking staffing levels and patient outcomes is limited. Staffing levels are implicated in adverse experiences of service users and staff within mental health ward settings, and they might contribute to levels of violence and aggression and the application of restrictive practices, such as physical restraint but there is limited research evidence to support this. Programmes such as Safewards, No Force First, the Engagement Model and the Six Core Strategies can reduce the use of restrictive practices. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: Staffing levels on acute mental health wards appeared crucial in the implementation of a restraint minimization project. Both staff and service users implicate insufficient staffing for deficiencies in the relational elements of care, such as lack of face-to-face contact between nurses and service users. Similarly, staffing levels are associated with perceived problems in the cause of violence and aggression and responses to it. Despite successes in minimizing restrictive practices in this project, difficulties implementing alternative forms of practice that would reduce use of physical restraint, such as de-escalation, were also attributed to staffing levels. There is an irony that a project concerned with safety itself provoked concern over safe staffing levels. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Efforts to reduce restrictive practices will be hampered without adequate staffing levels. Restrictive practices may justifyably be framed as an employment relations matter. Organisations and policy makers ought to address environmental, contextual and resourcing factors, rather than identify problems exclusively in terms of perceived aberrant behaviour of staff or service users. ABSTRACT: Introduction Safe staffing and coercive practices are of pressing concern for mental health services. These are inter-dependent, and the relationship is under-researched. Aim To explore views on staffing levels in a context of attempting to minimize physical restraint practices on mental health wards. Findings emerged from a wider data set with the broader aim of exploring experiences of a restraint reduction initiative. Methods Thematic analysis of semi-structured interviews with staff (n = 130) and service users (n = 32). Results Five themes were identified regarding how staffing levels impact experiences and complicate efforts to minimize physical restraint. We titled the themes-"insufficient staff to do the job"; "detriment to staff and service users"; "a paperwork exercise: the burden of non-clinical tasks"; "false economies"; and, "you can't do these interventions." Discussion Tendencies detracting from relational aspects of care are not independent of insufficiencies in staffing. The relational, communicative and organizational developments that would enable reductions in use of restraint are labour intensive and vulnerable to derailment by insufficient and poorly skilled staff. Implications for practice Restrictive practices are unlikely to be minimized unless wards are adequately staffed. Inadequate staffing is not independent of restrictive practices and reduces access to alternative interventions for reducing individuals' distress.

Staff experiences and understandings of the REsTRAIN Yourself initiative to minimize the use of physical restraint on mental health wards.

International efforts to minimize coercive practices include the US Six Core Strategies© (6CS). This innovative approach has limited evidence of its effectiveness, with few robustly designed studies, and has not been formally implemented or evaluated in the UK. An adapted version of the 6CS, which we called 'REsTRAIN Yourself' (RY), was devised to suit the UK context and evaluated using mixed methods. RY aimed to reduce the use of physical restraint in mental health inpatient ward settings through training and practice development with whole teams, directly in the ward settings where change was to be implemented and barriers to change overcome. In this paper, we present qualitative findings that report on staff perspectives of the impact and value of RY following its implementation. Thirty-six staff participated in semi-structured interviews with data subject to thematic analysis. Eight themes are reported that highlight perceived improvements in every domain of the 6CS after RY had been introduced. Staff reported more positively on their relationships with service users and felt their attitudes towards the use of coercive practices such as restraint were changed; the service as a whole shifted in terms of restraint awareness and reduction; and new policies, procedures, and language were introduced despite certain barriers. These findings need to be appreciated in a context wherein substantial reductions in the use of physical restraint were proven possible, largely due to building upon empathic and relational alternatives. However, yet more could be achieved with greater resourcing of inpatient care.

International variations in mental-health law regulating involuntary commitment of psychiatric patients as measured by the Mental Health Legislation Attitudes Scale.

Previous research illustrated that the laws regulating involuntary placement and treatment of people with mental-health problems are diverse across countries. International studies comparing satisfaction levels between countries are rare. We compared the opinions of professionals and family members about the operation of the national mental-health law regulating forcibly admission and treatment of psychiatric patients in 11 countries: Ireland, Iceland, England and Wales, Romania, Slovenia, Denmark, Germany, Sweden, Norway and India. An online survey design was adopted using a Mental Health Legislation Attitudes Scale (MHLAS). This brief nine-item questionnaire was distributed via email to psychiatrists, general practitioners, acute and community mental-health nurses, tribunal members, police officers and family members in each collaborating country. The levels of agreement/disagreement were measured on a Likert scale. Data were analysed both per question and with regard to a total MHLAS 'approval' score computed as a sum of the nine questions. We found that respondents in England and Wales and Denmark expressed the highest approval for their national legislation (76% and 74%, respectively), with those in India and Ireland expressing the lowest approval (65% and 64%, respectively). Almost all countries had a more positive attitude in comparison to Ireland on the admission criteria for involuntary placement and the way people are transferred to psychiatric hospitals. There are significant variations across Europe and beyond in terms of approval for how the national mental-health law framework operates in each country.

Minimising the use of physical restraint in acute mental health services: The outcome of a restraint reduction programme ('REsTRAIN YOURSELF').

BACKGROUND: Physical restraint is a coercive intervention used to prevent individuals from harming themselves or others. However, serious adverse effects have been reported. Minimising the use of restraint requires a multimodal approach to target both organisational and individual factors. The 'Six Core Strategies' developed in America, underpinned by prevention and trauma informed principles, is one such approach. OBJECTIVE: An adapted version of the Six Core Strategies was developed and its impact upon physical restraint usage in mental health Trusts in the United Kingdom evaluated. This became known as 'REsTRAIN YOURSELF. The hypothesis was that restraint would be reduced by 40% on the implementation wards over a six-month period. DESIGN: A non-randomised controlled trial design was employed. SETTING: Fourteen, adult, mental health wards from seven mental health hospitals in the North West of England took part in the study. Two acute care wards were targeted from all eligible acute wards within each site in negotiation with each Trust. The intervention wards (total n = 144 beds, mean = 20.1 beds per ward) and control wards (total n = 147 beds, mean = 21.0 beds per ward) were primarily mixed gender but included single sex wards also (2 female-only and 1 male-only in each group). All wards offered pharmacological and psychosocial interventions over short admission durations (circa 15 days) for patients with a mixture of enduring mental health problems. METHOD: As part of a pre and post-test method, physical restraint figures were collected using prospective, routine hospital records before and 6 months after the intervention. Restraint rates on seven wards receiving the REsTRAIN YOURSELF intervention were compared with those on seven control wards over three study phases (baseline, implementation and adoption). RESULTS: In total, 1680 restraint incidents were logged over the study period. The restraint rate was significantly lower on the intervention wards in the adoption phase (6.62 events/1000 bed-days, 95% CI 5.53-7.72) compared to the baseline phase (9.38, 95% CI 8.19-10.55). Across all implementation wards there was an average reduction of restraint by 22%, with some wards showing a reduction of 60% and others less so (8%). The association between ward type and study phase was statistically significant. CONCLUSION: In conclusion, it is possible that reductions in the use of physical restraint are achievable using a model such as the Six Core Strategies. This approach can be adapted for global settings and changes can be sustained over time with continued support.

The Management of Aggression and Violence Attitude Scale (MAVAS): a cross-national comparative study.

AIM: This paper is a report of a study to determine the transferability of the Management of Aggression and Violence Attitude Scale to European mental health inpatient settings. BACKGROUND: Incidents of patient aggression and violence are common in psychiatric in-patient facilities, and nurses' attitudes may play a part in how they are managed. METHODS: Nursing staff from acute psychiatric in-patient units in Switzerland and the United Kingdom completed the Management of Aggression and Violence Attitude Scale. Data were collected in the UK in 2001 and Switzerland in 2003. The Swiss sample comprised 75 respondents: 45 female, mean age 36.24, mean experience 7.35 years, 60 Registered Nurses. The United Kingdom sample was 75 respondents: 58 female, mean age 32, mean experience 5.25 years, 48 Registered Nurses. T-tests identified differences between the groups in their responses to each Management of Aggression and Violence Attitude Scale statement. RESULTS: There was 66% concordance of views between the groups. Swiss nurses were, however, more likely to regard factors internal to the patient as contributory to aggression while United Kingdom nurses perceived environmental factors to be more important. Both groups endorsed physical means of aggression management, Swiss nurses more so. CONCLUSION: There are both commonalities and differences between the attitudes of Swiss and United Kingdom nursing staff regarding patient aggression. Differences may relate to rates of aggression, variations in management approaches, training and policy. The Management of Aggression and Violence Attitude Scale is a potentially effective tool for making comparisons about perspectives on patient aggression.