Exploring the Safewards Programme to Reduce Restrictive Practices in Residential Aged Care: Protocol for a Pilot and Feasibility Study.

INTRODUCTION: Restrictive practice use in residential aged care homes internationally is unacceptably high. Although policies and legislation mandate the reduction or elimination of restrictive practices, there remains a gap in knowledge regarding strategies that have been effective in achieving a sustained reduction in restraint use. There is an urgent need to identify effective and feasible interventions that aged care staff can implement in everyday practice to reduce restraint use. Safewards is an evidence-based programme that has demonstrated effectiveness in reducing conflict and restrictive practice use in inpatient psychiatric settings and has the potential to address the issue of restraint use in aged care homes. This study aims to evaluate the feasibility of Safewards in reducing restrictive practices in residential aged care homes. METHODS: This pilot and feasibility study will adopt a mixed methods process and outcomes evaluation. Safewards will be implemented in two Australian residential aged care homes. The Reach, Effectiveness, Adoption, Implementation and Maintenance framework will be used to evaluate implementation outcomes. Additionally, the Consolidated Framework for Implementation Research will be used to guide qualitative data collection (including semi-structured interviews with residents/family members, aged care leaders and staff) and explain the facilitators and barriers to effective implementation. CONCLUSION: This study will provide pilot evidence on the feasibility of the Safewards programme in residential aged care homes. Understanding the processes and adaptations for implementing and evaluating Safewards in residential aged care will inform a future trial in aged care to assess its effectiveness. More broadly, the findings will support the implementation of an international aged care policy of reducing restrictive practices in residential aged care. PATIENT OR PUBLIC CONTRIBUTION: A person with lived experience of caring for someone with dementia is employed as a Safewards facilitator and is a member of the steering committee. Residents and family members will be invited to participate in the project steering committee and provide feedback on their experience of Safewards. TRIAL REGISTRATION: ACTRN12624000044527.

OPCAT: How an international treaty regarding torture is relevant to the Australian mental health system.

The United Nations Subcommittee on the Prevention of Torture visits signatory nations to the Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT). Its role is to monitor and support signatory nations in implementing and complying with the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (CAT). In October 2022, the United Nations Subcommittee on the Prevention of Torture visited Australia but was barred from visiting mental health wards in Queensland and all detention facilities in New South Wales leading to the termination of its visit. This breach of Australia's obligations under the OPCAT presents a significant setback for the rights of people with mental illness and other involuntarily detained populations. This piece sets out to demonstrate the relevance of OPCAT to the mental health system in Australia. Individuals who are detained for compulsory treatment in locked facilities such as acute psychiatric inpatient wards and forensic mental health facilities are deprived of their liberty, often out of public view. Thus, it highlights the ethical and professional obligations of all mental health professionals, especially psychiatrists, to safeguard the human rights of individuals being detained in mental health facilities as enshrined in Australia's international legal obligations under the OPCAT. Adhering to these obligations diminishes the risk of future human rights violations of people with mental illness.

'Becoming restrained': Conceptualising restrictive practices in the care of people living with dementia in acute hospital settings.

The use of restrictive practices within health and social care has attracted policy and practice attention, predominantly focusing on children and young people with mental health conditions, learning disabilities and autism. However, despite growing appreciation of the need to improve care quality for people living with dementia (PLWD), the potentially routine use of restrictive practices in their care has received little attention. PLWD are at significant risk of experiencing restrictive practices during unscheduled acute hospital admissions. In everyday routine hospital care of PLWD, concerns about subtle and less visible forms of restrictive practices and their impacts remain. This article draws on Deleuze's concepts of 'assemblage' and 'event' to conceptualise restrictive practices as institutional, interconnection social and political attitudes and organisational cultural practices. We argue that this approach illuminates the diverse ways restrictive practices are used, legitimatised and perpetuated in the care of PLWD. We examine restrictive practices in acute care contexts, understanding their use requires examining the wider socio-political, organisational cultures and professional practice contexts in which clinical practices occurs. Whereas 'events' and 'assemblages' have predominantly been used to examine embodied entanglements in diverse health contexts, examining restrictive practices as a structural assemblage extends the application of this theoretical framework.

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.

Staff responses to interventions aiming to reduce mechanical restraint in adult mental health inpatient settings: a questionnaire-based survey.

PURPOSE: To explore mental health staff's responses towards interventions designed to reduce the use of mechanical restraint (MR) in adult mental health inpatient settings. METHODS: We conducted a cross-sectional, questionnaire-based survey. The questionnaire, made available online via REDCap, presented 20 interventions designed to reduce MR use. Participants were asked to rate and rank the interventions based on their viewpoints regarding the relevance and importance of each intervention. RESULTS: A total of 128 mental health staff members from general and forensic mental health inpatient units across the Mental Health Services in the Region of Southern Denmark completed the questionnaire (response rate = 21.3%). A total of 90.8% of the ratings scored either 'agree' (45.2%) or 'strongly agree' (45.6%) concerning the relevance of the interventions in reducing MR use. Overall and in the divided analysis, interventions labelled as 'building relationship' and 'patient-related knowledge' claimed high scores in the staff's rankings of the interventions' importance concerning implementation. Conversely, interventions like 'carers' and 'standardised assessments' received low scores. CONCLUSIONS: The staff generally considered that the interventions were relevant. Importance rankings were consistent across the divisions chosen, with a range of variance and dispersion being recorded among certain groups.

Exploring the Utility of a Novel Approach of Evaluating Application of a Validated Violence Risk Assessment Instrument.

Mental health nurses are often responsible for assessment/management of inpatient aggression. Validated instruments such as the Dynamic Appraisal of Situational Aggression (DASA), can aid risk assessment. However, limited attention has been paid to evaluating nurses' ability to administer risk assessment instruments. An entrustable professional activity may offer way of evaluating risk assessment clinical activities. DASA trainers' perceptions of the value and utility of an EPA were explored via collection of data through focus groups, with 17 participants from six countries. Thematic analysis was conducted to analyze the data. Three themes were interpreted: (1) DASA trainers-a way of knowing and being (2) An EPA-something you did not know you need until you see it; (3) The DASA-EPA supports the need for training and importance of integrity in assessment. Trainers engaged in innovative ways to ensure training is suitable and responsive to needs of nurses and their setting. Participants understood how an EPA could be used to evaluate DASA administration, monitor DASA use, provide feedback, and highlight the importance of training to ensure best practice.

Art therapy is associated with a reduction in restrictive practices on an inpatient child and adolescent mental health unit.

BACKGROUND: The elimination of restrictive practices, such as seclusion and restraint, is a major aim of mental health services globally. The role of art therapy, a predominantly non-verbal mode of creative expression, is under-explored in this context. This research aimed to determine whether art therapy service provision was associated with a reduction in restrictive practices on an acute inpatient child and adolescent mental health services (CAMHS) unit. METHODS: The rate (events per 1,000 occupied bed days), frequency (percent of admitted care episodes with incident), duration, and number of incidents of restrictive practices occurring between July 2015 and December 2021 were analysed relative to art therapy service provision. The rate, frequency and number of incidents of intramuscular injected (IM) sedation, oral PRN (as-needed medication) use, and absconding incidents occurring in conjunction with an episode of seclusion or restraint were also analysed. RESULTS: The rate, frequency, duration, and total number of incidents of seclusion, the frequency and total number of incidents of physical restraint, and the rate, frequency and total number of incidents of IM sedation showed a statistically significant reduction during phases of art therapy service provision. CONCLUSIONS: Art therapy service provision is associated with a reduction in restrictive practices in inpatient CAMHS.

Neurocognitive Disorders: Medical Illness or Mental Disorder: Examining the Mental Health and Wellbeing Act 2022 (Vic) Using Neurocognitive Disorders.

Victoria has new legislation, the Mental Health and Wellbeing Act 2022 (Vic) (MHWA) to govern the care and treatment of people with mental illness that came into effect on 1 September 2023. It takes a human rights approach with a focus on person-centred care. The definition of mental illness encompasses conditions such as dementia even though it is rarely used to manage such conditions. How would the management of dementia and associated conditions change if these conditions were managed under the MHWA? This article uses dementia to examine the differences between the new MHWA, the Medical Treatment Planning and Decisions Act 2016 (Vic) and the Guardianship and Administration Act 2019 (Vic) and how the human rights approach taken by the MHWA might inform future directions in managing dementia.

Examining the need for a high level of therapeutic security at a regional forensic mental health service in Aotearoa New Zealand.

The ceiling of therapeutic security in Aotearoa New Zealand is medium security. The aim of this study is to identify and characterise a putative cohort of high-secure patients at a medium-secure regional forensic mental health service. A retrospective review of all admissions to a specific service was conducted over 3.75 years. The Dangerousness Understanding, Recovery and Urgency Manual, Triage Security Scale (DUNDRUM-1) was used to identify patients with high-secure care needs. A multiple logistic regression analysis was used to identify the local needs of this cohort. We found a significant incidence (an admission every 55 days) and prevalence (11%) of mixed-gendered and culturally diverse patients with high-secure care needs. The cohort had a high prevalence of psychosis and violent offences, and relatively short length of stay. There is also an indication that the cohort was subject to more restrictive practice. A solution is proposed to meet the needs of this cohort.

Restrictive Practices and the 'Need' for Positive Behaviour Support (PBS): A Critical Discourse Examination of Disability Policy Beliefs.

BACKGROUND: Few studies have considered policies which underpin the promotion of positive behaviour support (PBS). The present study examined policy beliefs about PBS and their relationship to restrictive practices. METHODS: Discourse network analysis (a combination of critical discourse analysis and social network analysis) was used. RESULTS: A total of 11 policies were examined from which 38 belief statements were coded. One cluster was identified which promoted 13 dominant beliefs. Dominant discourses related to law, safety and the environment were evident. A conceptual representation of the shared PBS beliefs demonstrated contradictions in PBS policy. CONCLUSIONS: There is evidence that PBS policies have become informal rules for using restrictive practices, not reducing them. They are also acting as surrogates to debate conflicts between political, personal and bureaucratic interests. Three recommendations for improved PBS policy are provided.

Adolescent psychiatric inpatients' perceptions of treatment and seclusion.

Objectives: A great deal of attention is being directed at the use of seclusion in adolescent inpatient psychiatric units due to its forceful nature and negative impact on inpatients and staff. This mixed methods study aimed to explore and compare the level of satisfaction with the services received and perspectives on seclusion in secluded and non-secluded adolescent inpatients.Methods: This study included 188 participants, across three adolescent inpatient psychiatric units in Australia; 17% reported having experienced seclusion. A mixed methods approach was employed. Participants completed the Consumer Satisfaction Questionnaire-8 and Perceptions of Treatment and Seclusion Questionnaire shortly before or at discharge. Qualitative data was analysed using thematic analysis.Results: Secluded participants were more likely to report issues with broader care experiences on the Consumer Satisfaction Questionnaire-8. Secluded individuals reported ongoing negative effects from seclusion but were more likely than non-secluded participants to believe seclusion is necessary. Qualitative analyses showed that both secluded and non-secluded individuals considered seclusion to be traumatic, many did not agree with its use.Conclusions: Communication between inpatients and staff regarding seclusion needs to be improved and there needs to be ongoing support in relation to seclusion during and after discharge. Many adolescent inpatients acknowledge the necessity of seclusion whilst advocating for reduced seclusion.

Benchmarking to reduce restrictive practices in forensic mental health services: a Delphi study.

OBJECTIVES: Forensic mental health services (FMHS) have higher rates, duration and frequency of restrictive practices (seclusion, physical restraint and mechanical restraint). Data generated by services can be used to set targets (benchmarks) with like services to reduce or eliminate restrictive practices. The aim of this study was to develop restrictive practice benchmarks for Australian and New Zealand FMHS. METHOD: A participatory action research methodology was used by conducting a Delphi study. FMHS experts provided de-identified service-specific restrictive practice data, which was used to stimulate reflection towards the development of restrictive practice benchmarks. RESULTS: Consensus decision-making was reached on benchmarks for the rate, duration and frequency of seclusion and physical restraint. Mechanical restraint was found to be a rare event, requiring event specific review in each service. CONCLUSIONS: Benchmarking with FMHS may assist in working to reduce restrictive practices and encourage the scrutiny of service practice. Establishment of a FMHS network might assist to embed the proposed benchmarks.

Gender, Trauma and the Regulation of the Use of Restraint on Women in Australian Mental Health Services.

The use of physical, mechanical and/or chemical restraint is authorised by mental health legislation in most Australian jurisdictions. Research indicates that women have different experiences and needs in relation to the use of restraint, but legislation does not mention sex or gender as relevant considerations in the authorisation, use or monitoring of these practices. This is especially problematic in light of the potential for restraint use to traumatise, or retraumatise, women service users. This section discusses the treatment of gender- and trauma-related considerations in Australian mental health legislation and supporting policy, pointing to several gaps and proposing appropriate changes to practice and regulation.

Chemical restraint of adults with intellectual disability and challenging behaviour in Queensland, Australia: Views of statutory decision makers.

BACKGROUND: Psychotropic medication is widely prescribed to treat mental illness. However, it is controversial when used as a chemical restraint (CR) to manage challenging behaviours (CBs) of adults with intellectual disability (ID). CR has potentially negative consequences and affects human rights. METHOD: Qualitative research conducted between 2014 and 2015 explored the views of 'guardian' decision makers appointed under unique Queensland legislation oversighting the use of CR. RESULTS: Findings included (1) negative conceptualization of CR, (2) concerning relationships with prescribers and disability sector staff, (3) challenges to information seeking about people with ID prescribed CR and (4) problematic implementation of positive behaviour support plans. CONCLUSION: According to guardians, CR may be used in lieu of community supports, and prescribers sometimes diagnose mental illness to avoid CR legislative requirements. Guardians, prescribers and professionals would benefit from training that addresses the intersection between physical and mental health, CB and CR.

Rapid tranquillisation: an issue for all nurses in acute care settings.

The management of challenging behaviour, violence and aggression is not only an issue for mental health and learning disability nurses. Increasingly, nurses working in emergency departments (EDs), medical assessment units and general medical or surgical wards may encounter acts of challenging behaviour, violence and aggression on a regular basis. Restraint is sometimes used as a tool in the management of these patients; this may be in the form of physical, mechanical or chemical restraint. Rapid tranquillisation (RT) is often considered a form of chemical restraint, which may be used in an emergency situation when prescribed. If RT is given it should be done so as the least restrictive option, with intramuscular and intravenous administration as a last resort. Patient monitoring following administration is paramount. This article explores best practice in the administration of RT from a clinical perspective.

Patient perspectives on barriers and enablers to the use and effectiveness of de-escalation techniques for the management of violence and aggression in mental health settings.

AIM: Investigate patient perspectives on barriers and enablers to the use and effectiveness of de-escalation techniques for aggression in mental health settings. BACKGROUND: De-escalation techniques are the recommended first-line intervention for the management of aggression in mental health settings internationally, yet use of higher risk restrictive practices persists. This indicates de-escalation techniques are not used at optimum frequency and/or there are important factors limiting their use and effect. DESIGN: Descriptive qualitative research using semi-structured interviews and Framework Analysis. METHODS: Inpatient interviews (N = 26) exploring staff, patient and environmental factors influencing the use and effectiveness of staff de-escalation were conducted mid-2014. Three service user researchers led analysis. RESULTS: Data were synthesized in three deductive themes relating to staff, patient and environmental influences on the use and effectiveness of de-escalation techniques. The dominant view was that restrictive practices, rather than de-escalation techniques, are used in response to escalating patient behaviour. Under-use of de-escalation techniques was attributed to: lack of staff reflection on culture and practice and a need to retain control/dominance over patients. Ward rules, patient factors and a lack of staff respect for patients diluted their effectiveness. Participants identified a systematic process of de-escalation, rule subversion, reduced social distance and staff authenticity as enablers of effective de-escalation. CONCLUSION: This study investigated patient perspectives on staff, patient and environmental influences on the use and effectiveness of de-escalation techniques. Our framework of barriers and enablers provides indicators of organizational/behaviour change targets for interventions seeking to reduce violence and restrictive practices through enhanced de-escalation techniques.

Alternatives to Compulsory Detention and Treatment and Coercive Practices in Mental Health Settings.

Informed consent to medical treatment is generally presumed to be central to the provision of good quality health care. Despite this presumption, legislation exists in many countries that enables the compulsory detention and treatment of people with severe mental health conditions regardless of their wishes. This column discusses global efforts to reduce, prevent and end compulsory detention, treatment and coercive practices in mental health and community settings. It summarises the current state of research, identifying overarching themes in the search for effective non-coercive practices, before focusing on hospital and community-based initiatives.

Co-designing restrictive practice elimination: A systems thinking approach with mental health service users and practitioners in rural/regional Australia.

Elimination of restrictive practices (physical/mechanical restraint and seclusion) from adult acute mental health care services has been demanded internationally for many decades. This study aimed to: (1) Identify priority issues in the elimination of and use of alternative approaches to restrictive practices (seclusion and physical/mechanical restraint) in rural/regional acute adult mental healthcare services, as told by mental healthcare service users and practitioners, (2) identify the community-based, system-level feedback loops that enhance or reduce the use of restrictive practices and viable alternatives and, (3) identify potential action areas to improve system structures to increase regional mental healthcare services' ability to eliminate restrictive practices and use alternative approaches. Group model building (GMB) workshops were held with a small group (n = 9) of mental healthcare practitioners and service users with lived experience of restrictive practice use. This participatory approach enables exploration and visual mapping of local structures causing behaviour patterns of practitioner and service user concern over time - in this case, the barriers, and enablers to alternative approaches to restrictive practices in adult acute mental healthcare services within the Geelong-Barwon region. This is the first study that specifically applies GMB in the discussion of the elimination of restrictive practices in mental health in the non-metropolitan regional/rural context. Participants identified four key priorities in relation to eliminating restrictive practices: (1) self-advocacy, (2) continuity of care, (3) early intervention, and (4) safety for all. The study findings were distilled into a novel preliminary set of mental healthcare practitioner and service user action ideas.

A Pioneer Tool to Reduce Restrictive Practices toward People with Intellectual and Developmental Disabilities.

Reducing restrictive practices toward individuals with intellectual and developmental disabilities is a globally recognized imperative and human rights priority. This paper presents a novel tool called LibRe for assessing and reducing restrictive practices. This tool involved an instrumental multistage design and collaboration between professionals, individuals with disabilities, family members, and experts from different fields. It addresses diverse restrictive practices in five key domains: physical or mechanical, chemical or pharmacological, structural, relational, and practices related to contexts and supports. It addresses practices that are pertinent to the Spanish context and that existing tools have not covered. Embedded as a step within an organizational approach, LibRe fosters organizational transformation and provides resources to achieve outcomes within reduction plans for restrictive practices. In total, 156 teams comprising 585 professionals, 64 people with disabilities, and 44 family members responded to the tool. In terms of evidence for internal structure validity, the oblique five-factor model exhibited an adequate fit through confirmatory factor analysis, along with satisfactory reliability indices, according to ordinal alpha and omega. Users positively appraised the tool's usefulness and identified its strengths and challenges. Although further research is needed, preliminary evidence frames LibRe as a useful resource for practice and research.

The importance of individualised care, good communication and trust for reducing nasogastric tube feeding under physical restraint: qualitative multi-informant study.

BACKGROUND: Nasogastric tube (NGT) feeding against a patient's consent is an intervention that clinicians working in specialist mental health in-patient units may need to implement from time to time. Little research has explored clinician, patient and carer perspectives on good practice. AIMS: To use qualitative data from people with lived experience (PWLE), parents/carers and clinicians, to identify components of best practice when this intervention is required. METHOD: PWLE and parents/carers were recruited via BEAT UK's eating disorder charity. Clinicians were recruited via a post on The British Eating Disorders Society's research page. Semi-structured interviews were administered, transcribed and thematically analysed. RESULTS: Thirty-six interviews took place and overlapping themes were identified. Participants spoke in relation to three themes: first, the significance of individualised care; second, the importance of communication; third, the impact of staff relationships. Sub-themes were identified and explored. CONCLUSIONS: Good care evolved around positive staff relationships and individualised care planning rather than standard processes. The centrality of trust as an important mediator of outcome was identified, and this should be acknowledged in any service that delivers this intervention.