Sustaining a therapeutic environment within mental health in-patient settings during COVID-19. Results of a Delphi study.

AIM: Develop a strengths-based, person-centred, trauma-informed and recovery-oriented framework to mitigate any potential increase in conflict resulting from the implementation of C19 restrictions. BACKGROUND: Guidance addressing the unique challenges posed by Covid-19 within mental health in-patient settings, including how to support those whose distress may present as behaviour that challenges including violence and self-harm, remains urgently needed. METHODOLOGY/APPROACH: A Delphi design involving four iterative stages was adopted. Stage 1 involved a review and synthesis of COVID-19-related public health and ethical guidance and a narrative literature review. A formative operational framework was then developed. Stage 2 sought to establish the face validity of the framework through engagement with frontline and senior staff in mental health services in Ireland, Denmark and Netherlands. Stage 3 investigated the content validity of the final framework through a plenary presentation and discussion of the framework at a scientific symposium of the European Violence in Psychiatric Research Group (EViPRG, 2020). Stage 4 sought expert appraisal of the framework using a structured evaluation completed by a panel of eighteen multidisciplinary experts from nine countries, including four academics, six clinicians and eight holding dual clinical/academic appointments to assess content validity. RESULTS: The guidance adopts the widely advocated approach to support those whose distress may present as behaviour services find challenging in identifying the need for primary, secondary, tertiary and recovery measures. It emphasizes person-centred care while integrating specific Covid-19 public health requirements into service planning. It also aligns with contemporary best practice in in-patient mental health care, incorporating the principles of Safewards, the core values of trauma-informed care, and an explicit on recovery. CONCLUSION: The guidance developed has face and content validity.

Restraint in mental health settings: is it time to declare a position?

The emergence of a drive to reduce restrictive interventions has been accompanied particularly in the UK by a debate focussing on restraint positions. Any restraint intervention delivered poorly can potentially lead to serious negative outcomes. More research is required to reliably state the risk attached to a particular position in a particular clinical circumstance.Declaration of interestF.S. is a consultant psychiatrist in Psychiatric Intensive Care at the Maudsley Hospital, London. He is on the Executive Committee of the National Association of Psychiatric Intensive Care and Low Secure Units, and was a member of the National Institute for Health and Care Excellence Guideline Development Group for the Short-Term Management of Aggression and Violence (2015). J.P. is a senior lecturer at the Faculty of Health and Life Sciences, Coventry University. E.B. is a consultant and expert witness in violence reduction and the use of physical interventions, independent expert to the High Secure Hospitals Violence Reduction Manual Steering Group and a member of the College of Policing Guideline Committee Steering Group and Mental Health Restraint Expert Reference Group. B.P. is the clinical director for Crisis and Aggression Limitation and Management (CALM) Training and formerly a senior lecturer for the Faculty of Health, University of Stirling. He is a nurse and psychotherapist and presently chairs the European Network for Training in the Management of Aggression. A.O'B. is a consultant psychiatrist, the Director of Educational Programmes for the National Association of Psychiatric Intensive Care and Low Secure Units, and the Dean for Students at St George's University of London.

Trampoline-related injuries in children: a preliminary biomechanical model of multiple users.

BACKGROUND: The recent popularity of domestic trampolines has seen a corresponding increase in injured children. Most injuries happen on the trampoline mat when there are multiple users present. This study sought to examine and simulate the forces and energy transferred to a child's limbs when trampolining with another person of greater mass. METHODS: The study used a computational biomechanical model. RESULTS: The simulation demonstrated that when two masses bounce out of phase on a trampoline, a transfer of kinetic energy from the larger mass to the smaller mass is likely to occur. It predicted that when an 80 kg adult is on a trampoline with a 25 kg child, the energy transfer is equivalent to the child falling 2.8 m onto a solid surface. Additionally, the rate of loading on the child's bones and ligaments is greater than that on the accompanying adult. CONCLUSIONS: Current guidelines are clear that more than one user on a trampoline at a time is a risk factor for serious injury; however, the majority of injuries happen in this scenario. The model predicted that there are high energy transfers resulting in serious fracture and ligamentous injuries to children and that this could be equated to equivalent fall heights. This provides a clear take-home message, which can be conveyed to parents to reduce the incidence of trampoline-related injuries.

Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation.

The British Association for Psychopharmacology and the National Association of Psychiatric Intensive Care and Low Secure Units developed this joint evidence-based consensus guideline for the clinical management of acute disturbance. It includes recommendations for clinical practice and an algorithm to guide treatment by healthcare professionals with various options outlined according to their route of administration and category of evidence. Fundamental overarching principles are included and highlight the importance of treating the underlying disorder. There is a focus on three key interventions: de-escalation, pharmacological interventions pre-rapid tranquillisation and rapid tranquillisation (intramuscular and intravenous). Most of the evidence reviewed relates to emergency psychiatric care or acute psychiatric adult inpatient care, although we also sought evidence relevant to other common clinical settings including the general acute hospital and forensic psychiatry. We conclude that the variety of options available for the management of acute disturbance goes beyond the standard choices of lorazepam, haloperidol and promethazine and includes oral-inhaled loxapine, buccal midazolam, as well as a number of oral antipsychotics in addition to parenteral options of intramuscular aripiprazole, intramuscular droperidol and intramuscular olanzapine. Intravenous options, for settings where resuscitation equipment and trained staff are available to manage medical emergencies, are also included.

Developing a perspective on restraint and the least intrusive intervention.

This article explores contemporary practice in the use of restraint in the light of recent European Council Guidance endorsing the principles of least restrictive environment/least intrusive intervention. Violence is a source of concern in many European mental health services but approaches to its immediate management continue to display remarkable diversity reflecting the adoption of differing perspectives on what constitutes 'least intrusiveness'. This article examines the basis for practice in terms of the range of procedures available, reviews the literature on restraint safety and presents a model based on the concept of reasonableness which can be used to evaluate whether a given intervention meets the European guidance. Current practice across Europe is largely a function of tradition and local values rather then evidence based. Collaborative large-scale studies are required to determine the relative risks of the range of interventions in use such that practice is informed by evidence rather than opinion.

Long- and short-term risk factors in the prediction of inpatient suicide: review of the literature.

The prediction of suicide remains a major challenge for health care professionals in inpatient settings. A clearer identification of factors specific to inpatient suicide is required to improve both practice and research within this area. This paper provides an overview of the inpatient suicide literature to date focusing on two particularly salient themes: Long term and short term prediction of suicide. Since the concept of short-term suicide risk dominates clinical practice, issues in relation to dynamic risk factors are emphasized.

Beyond Zero Tolerance: a varied approach to workplace violence.

Violence in the health- and social-care workplace remains unexplored, with a knowledge base which is often ambiguous or incomplete. However, the issue has attracted increasing attention over the last two decades as indicated by an expanding range of policy initiatives and growing research literature. Additionally, a proliferation of training programmes for healthcare staff has appeared. This paper will explore the reasons for an observed tendency for interventions to focus on training as the primary response, which suggests a misperception of the problem of violence as principally a function of interpersonal conflict. It argues that a radical cultural shift is needed, which recognises the organizational and societal roots of violence, and that adopts and applies the principles of a public health approach.

New evidence or changing population? Reviewing the evidence of a link between mental illness and violence.

There has been an apparent shift in majority opinion within psychiatry over the last 20 years on the nature of the relationship between mental illness and violence. Where once there was perhaps widespread scepticism, research, while sometimes producing conflicting results, appears ultimately to have led to the emergence of an almost universal consensus that there is a link. This paper will review the nature of the evidence for such a link between mental illness and violence and explore some of the newer suggestions about why mental illness may sometimes be related to violence.

Zero in on violence.

THE RECOGNITION of violence in the healthcare workplace as a potential threat to the welfare of nurses has focused largely on the prevention of violence. However, it is now accepted that although violence may be reduced, it will not be eliminated ( Bowie 1996 ), and interest has grown in how nurses and other healthcare workers exposed to assault, verbal abuse or other forms of violence can be supported.

Manual restraint and shows of force: the City-128 study.

Manual restraint is used to manage disturbed behaviour by patients. This study aimed to assess the relationship of manual restraint and show of force to conflict behaviours, the use of containment methods, service environment, physical environment, patient routines, staff characteristics, and staff group variables. Data from a multivariate, cross-sectional study of 136 acute psychiatric wards in England were used to conduct this analysis. Manual restraint was used less frequently on English acute psychiatric wards (0.20 incidents per day) than show of force (0.28 incidents per day). Both were strongly associated with the proportion of patients subject to legal detention, aggressive behaviours, and the enforcement of treatment and detention. Medical, nursing, and security guard staff provision were associated in different ways with variations in the use of these coercive interventions. An effective ward structure of rules and routines was associated with less dependence on these control methods. Training for manual restraint should incorporate the scenarios of attempted absconding and enforcement of treatment, as well as violent behaviour. Attempts to lessen usage of these interventions could usefully focus on increasing the availability of medical staff to patients, reducing reliance on security guards and establishing a good ward structure.

Re-framing the problem of workplace violence directed towards nurses in mental health services in the UK: a work in progress.

BACKGROUND: Research consistently suggests nurses working in mental health settings are more likely to be assaulted than nurses in other settings. AIMS: Belated recognition of the issue in terms of social policy (Elston et al. 2006) has been accompanied by an as yet unexamined contest between conflicting 'frames' of the problem, which this paper seeks to make transparent. METHOD: Frame analysis. RESULTS: Two distinct 'master' frames are discussed: the 'individualizing' and the 'co-creationist'. CONCLUSIONS: The influence of these frames has influenced the nature of responses to the problem but the recent dominance of the individualizing frame is being challenged by the emergence, or perhaps re-emergence, of co-creationism.

Accounting for accountability: a discourse analysis of psychiatric nurses' experience of a patient suicide.

Whilst the experience of a patient suicide is likely to have a significant impact upon the nurses who had been providing care, little work has actually explored this experience in any depth. In this article we explore how two psychiatric nurses construct and orient to accountability when talking of their experiences of a patient suicide. Discourse analysis was used to explore particular phases that the nurses oriented to in their accounts: scene setting; risk assessment; attributing for the suicide. Findings highlight the different, sometimes contradictory, ways the nurses attended to interactional concerns relating to implicit accountability and potential inferences of blame. Analysis of the nurses' talk can make a valuable contribution to understanding the nature and the impact of 'accountability' in a mental health setting and so help nurses and other professionals gain an insight into their practice. The results from this study suggest that as a consequence of internalising fundamentally unrealisable expectations regarding suicide prevention, nurses can hold themselves to blame raising significant concerns around their needs in terms of support, which may not be recognised. This paper also makes a valuable contribution to our methodological understanding and the value of using discourse analysis in this setting.

Comparison of traditional and interactive teaching methods in a UK emergency department.

Didactic teaching remains a core component of undergraduate education, but developing computer assisted learning (CAL) packages may provide useful alternatives. We compared the effectiveness of interactive multimedia-based tutorials with traditional, lecture-based models for teaching arterial blood gas interpretation to fourth year medical students. Participants were randomized to complete a tutorial in either lecture or multimedia format containing identical content. Upon completion, students answered five multiple choice questions assessing post-tutorial knowledge, and provided feedback on their allocated learning method. Marks revealed no significant difference between either group. All lecture candidates rated their teaching as good, compared with 89% of the CAL group. All CAL users found multiple choice questions assessment useful, compared with 83% of lecture participants. Both groups highlighted the importance of interaction. CAL complements other teaching methods, but should be seen as an adjunct to, rather than a replacement for, traditional methods, thus offering students a blended learning environment.

Severe hypoglycaemia in citalopram overdose.

We present two episodes of poisoning with citalopram in which the main feature was profound hypoglycaemia. Citalopram has been regarded as the most toxic of the selective serotonin reuptake inhibitors in overdose; however, hypoglycaemia is not one of the documented features of overdose. This is an important component of the toxicological profile of citalopram and a treatable cause of seizure activity that should be reported in poisoning information references.

A discourse analysis of the construction of mental illness in two UK newspapers from 1985-2000.

This study explored the discourse of mental illness contained within two UK newspapers over a 15-year period, excluding those stories that mentioned any reference to a diagnosis. Using frame analysis, a form of discourse analysis, ten distinct frames were identified and classified into "stories." These ten stories were categorized as: foreign, legal, drug, feature, trauma, tragedy, community care tragedy, social policy, inquiry report, and sports/celebrity stories. Each frame is described and the potential influence of such frames on both social policy and nursing practice is discussed.

Restraint and the question of validity.

Restraint as an intervention in the management of acute mental distress has a long history that predates the existence of psychiatry. However, it remains a source of controversy with an ongoing debate as to its role. This article critically explores what to date has seemingly been only implicit in the debate surrounding the role of restraint: how should the concept of validity be interpreted when applied to restraint as an intervention? The practice of restraint in mental health is critically examined using two post-positivist constructions of validity, the pragmatic and the psychopolitical, by means of a critical examination of the literature. The current literature provides only weak support for the pragmatic validity of restraint as an intervention and no support to date for its psychopolitical validity. Judgements regarding the validity of any intervention that is coercive must include reference to the psychopolitical dimensions of both practice and policy.

Press must take some responsibility for fear.

Jeremy Laurence's description of the mental health services (perspectives November 17) will ring true for many practitioners. He says it is obsessed with the prevention of violence and suicide to the detriment of collaborative engagement with service users.