Patients Subject to High Levels of Coercion: Staff's Understanding

Abstract

Measures to keep staff and patients safe (containment) frequently involve coercion. A small proportion of patients is subject to a large proportion of containment use. To reduce the use of containment, we need a better understanding of the circumstances in which it is used and the understandings of patients and staff. Two sweeps were made of all the wards, spread over four hospital sites, in one large London mental health organization to identify patients who had been subject to high levels of containment in the previous two weeks. Data were then extracted from their case notes about their past history, current problem behaviours, and how they were understood by the patients involved and the staff. Nurses and consultant psychiatrists were interviewed to supplement the information from the case records. Twenty-six heterogeneous patients were identified, with many ages, genders, diagnoses, and psychiatric specialities represented. The main problem behaviours giving rise to containment use were violence and self-harm. The roots of the problem behaviours were to be found in severe psychiatric symptoms, cognitive difficulties, personality traits, and the implementation of the internal structure of the ward by staff. Staff's range and depth of understandings was limited and did not include functional analysis, defence mechanisms, specific cognitive assessment, and other potential frameworks. There is a need for more in-depth assessment and understanding of patients' problems, which may lead to additional ways to reduce containment use.

Seclusion and Psychiatric Intensive Care Evaluation Study (SPICES): combined qualitative and quantitative approaches to the uses and outcomes of coercive practices in mental health services

“…As such, this study supports others demonstrating 'therapeutic poverty' in UK psychiatric nursing practice. 87 4. Non-standard transfer: move of the patient to another ward providing more secure or intensive care in some fashion, perhaps in a private hospital or in a neighbouring trust, or via a secure rehabilitation ward or a forensic ward of some type.…”

Repression in Residential Youth Care: A Scoping Review

“…If so, in which situations should coercion be considered acceptable, and which particular types of coercion are safe and effective? This debate is also relevant for the field of residential youth settings, because restraint and seclusion continue to be used on youth in residential settings at higher rates than on adults in care (Bowers et al 2014;LeBel et al 2010). Researchers have found that restraint is used on 30 % of youth in juvenile facilities, schools, and residential treatment programs (Kennedy and Mohr 2001), and that noncompliance is often the starting point of coercive cycles (Smith and Bowman 2009).…”

“…Less qualified staff also consider annoying behavior of patients to be an adequate reason for restraint (Gelkopf et al 2009). It has been suggested (Bowers et al 2014;Gelkopf et al 2009;Nelson et al 2010) that these results may stem from a lack of tools for coping with annoying actions and insufficient knowledge of psychopathology, which could explain the patients' annoying behavior. Researchers (Van der Helm et al 2006) also pointed to fear of losing control and lack of leadership, which can lead to a loss of patience and an inability to cope with the situation without physical restraints.…”

Narrative Case Notes Have the Potential to Predict Seclusion 3 Days in Advance: A Mixed-Method Analysis

“…Perceptions, attitudes, and emotional reactions of staff and patients are considered to affect interactional behavior preceding aggressive incidents (15–19). An example for problematic behavior given by Bowers et al (20) describes health care professional frustration due to repetitive requests at inappropriate times concerning a trivial item. The type of management that is used to deal with problematic patient behavior influences the interactional response and may lead to an escalation (8, 21–23).…”

“…Escalation can, e.g., be triggered by a controlling (15, 24, 25), over-confident, and punitive management approach by staff (26–29). In addition, restrictive regiments like limiting patients' freedom or denying patients' requests appear to be an essential antecedent of aggressive behavior (10, 14, 20, 30, 31).…”