PhD thesis
Jesper Bak
Mechanical Restraint
Preventive Factors in Theory and Practice
Academic advisor: Mette Brandt-Christensen
Submitted: 29/01/15
Title: Mechanical Restraint
Subtitle: Preventive Factors in Theory and Practice
Subject description: Identifying mechanical restraint factors to generate knowledge of non-medical
MR-prevention.
Author: Jesper Bak
The studies were completed at Mental Health Centre Sct. Hans, Research Institute, Boserupvej 2,
4000 Roskilde, Denmark and St. Olavs University Hospital, Forensic Department Bröset, Centre for
Research & Education in Forensic Psychiatry, Norway, while the author was a PhD student at the
University of Copenhagen, Faculty of Health, and Medical Science, University of Copenhagen,
Denmark.
Supervisors:
Mette Brandt-Christensen, MD, PhD, Head of Department, Department Q, Mental Health Centre
Glostrup, Glostrup, Denmark.
Dorte Maria Sestoft, MD, PhD, Head of Clinic, Clinic of Forensic Psychiatry, Ministry of Justice,
Copenhagen, Denmark.
Vibeke Zoffmann, RN, MPH, PhD, Head of Research, Women and Children’s Health, Juliane
Marie Centre, Rigshospitalet, Copenhagen, Denmark.
Assessment committee:
Ingrid Egerod, Clinical Professor, Department of Clinical Medicine, University of Copenhagen and
Trauma Centre, Rigshospitalet, Copenhagen, Denmark (Chair).
Lise Hounsgaard, Professor, Odense Patient data Explorative Network, Institute of Clinical
Research, University of Southern Denmark, Odense, Denmark.
Frans Fluttert, Associate Professor, Centre for Research and Education in Forensic Psychiatry,
Ullevål University Hospital, Oslo, Norway, and senior researcher, FPC Dr. S. Van Mesdag,
Groningen, The Netherlands.
This thesis has been submitted to the Graduate School of the Faculty of Health and Medical
Sciences, University of Copenhagen.
2015 © All rights reserved. No part of this publication may be reproduced in any form or by any
means without clear indication of the source. DOI: 10.13140/RG.2.1.2681.5528
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
1 Table of Contents
1
2
TABLE OF CONTENTS........................................................................................................... 1
PREFACE................................................................................................................................... 2
2.1
2.2
2.3
2.4
2.5
3
SUMMARIES IN DANISH AND ENGLISH ........................................................................... 5
3.1
3.2
4
5
6
7
Summary in Danish (Dansk Resumé) ..................................................................................................... 5
Summary in English .................................................................................................................................... 7
INTRODUCTION ....................................................................................................................... 8
OBJECTIVE ............................................................................................................................. 13
DESIGN AND METHODS ..................................................................................................... 14
RESULTS ................................................................................................................................. 24
7.1
7.2
7.3
7.4
8
9
Acknowledgements ..................................................................................................................................... 2
List of Papers ................................................................................................................................................ 3
Table of Contents: Figures, Tables, and Appendixes ......................................................................... 3
List of Symbols and Abbreviations ......................................................................................................... 4
Key Definitions .............................................................................................................................................. 4
Summary of Results, Study 1 .................................................................................................................. 24
Summary of Results, Study 2 .................................................................................................................. 27
Summary of Results, Study 3 .................................................................................................................. 29
Summary of Results, Study 4 .................................................................................................................. 31
APPROVAL AND ETHICS .................................................................................................... 35
DISCUSSION ........................................................................................................................... 35
9.1
Discussion of Individual Studies ........................................................................................................... 35
9.2
Design Issues .............................................................................................................................................. 45
9.3
Cause and Effect ........................................................................................................................................ 47
9.3.1 Chance..................................................................................................................................................... 47
9.3.2 Bias........................................................................................................................................................... 48
9.3.3 Confounding ............................................................................................................................................ 50
9.3.4 Strength of the Association ................................................................................................................... 51
9.3.5 Biological Credibility ............................................................................................................................... 51
9.3.6 Generalisability and Consistency ......................................................................................................... 52
9.4
Discussion of International High Quality Research .......................................................................... 52
10 CONCLUSIONS ...................................................................................................................... 54
10.1
10.2
Conclusions from the Individual Studies ............................................................................................. 54
General Conclusions ................................................................................................................................. 55
11 PERSPECTIVES ..................................................................................................................... 56
11.1
11.2
Clinical Implications .................................................................................................................................. 56
Future Research Recommendations ..................................................................................................... 57
12 REFERENCE LIST ................................................................................................................. 58
13 APPENDIX ............................................................................................................................... 68
13.1
Appendix A................................................................................................................................................... 68
Paper 1
Paper 2
Paper 3
Paper 4
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MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
2 Preface
This thesis addresses the mechanical restraint (MR) of adult psychiatric inpatients. I have dealt with
this phenomenon for many years, first as a nurse in acute psychiatry later as a clinical nurse
manager of closed units, and finally as a worker in the education and development field. I have
always tried to minimise the use of MR by delivering empowering and humanistic nursing care and
simultaneously introducing safe and secure nursing procedures. Although some reduction in the use
of MR has been observed locally, much more progress is needed. The question thus arises of which
procedures, interventions or conditions we should develop and implement. When interviewing
patients in 2004 to collect their suggestions on how to reduce the number of MR episodes, they
gave many suggestions, convincing me that my research should generate knowledge of non-medical
MR-prevention. I hereby present this thesis.
2.1
Acknowledgements
I thank The Mental Health Centre Sct. Hans, especially Margit Asser, for supporting my PhD
education.
I would like to thank Mette Brandt-Christensen, Dorte Maria Sestoft and Vibeke Zoffmann for their
continual advice and supervision.
I would like to thank Thomas Werge and my co-workers at the research institute for helping me
with countless questions and for being my colleagues.
I would like to thank Roger Almvik and my former colleagues in Norway at the Bröset Centre for
Research and Education in Forensic Psychiatry for the interesting discussions and guidance and for
“having me around” in autumn 2010.
I would like to thank Helle Aggernæs, Mette Dons, Torben Hærslev and Louise Gjørup for their
collaboration on the European study.
I would like to thank Volkert Siersma for supervising the statistical analyses and enduring my
endless questions.
I would like to thank the clinical nurse managers of the psychiatric units in Norway and Denmark:
this study would not have been possible without you spending time on the questionnaires.
2
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
Special thanks are extended to some of the clinical nurse managers of the units at Mental Health
Department Østmarka, Mental Health Centre Copenhagen and Mental Health Centre Sct. Hans for
helping to pilot the questionnaire.
Finally, on a personal level, I would like to thank my family for their patience when the study
demanded late hours and months of separation that kept my attention away from them.
I would like to thank the following organisations for funding this project: the Mental Health Centre
Sct. Hans, the Health Science Research Foundation in the Capital Region of Denmark, the Mental
Health Services in the Capital Region of Denmark, Copenhagen University Hospital and the
National Board of Health.
2.2
List of Papers
1. Bak, J., Brandt-Christensen, M., Sestoft, D. M., and Zoffmann, V. Mechanical Restraint Which Interventions Prevent Episodes of Mechanical Restraint? - A Systematic Review.
Perspectives in Psychiatric Care 48, 83-94. 2011.
2. Bak, J. and Aggernæs, H. Coercion within Danish psychiatry compared with 10 other European
countries. Nordic Journal of Psychiatry 66(5), 297-302. 2011.
3. Bak, J., Zoffmann, V., Sestoft, D. M., Almvik, R., and Brandt-Christensen, M. Mechanical
Restraint in Psychiatry: Preventive Factors in Theory and Practice. A Danish-Norwegian
Association Study. Perspectives in Psychiatric Care 50(3), 155-166. 2014.
4. Bak, J., Zoffmann, V., Sestoft, D. M., Almvik, R., Siersma, V. D., and Brandt-Christensen, M.
Comparing the effect of non-medical mechanical restraint preventive factors between
psychiatric units in Denmark and Norway. Nordic Journal of Psychiatry 23(1), 1-11. 2015.
2.3
Table of Contents: Figures, Tables, and Appendixes
Figure 1:
Mechanical Restraints in Denmark, 2004-2013
Figure 2:
Effect and Recommendation Grade Matrix
Table 1:
Hierarchy of Mechanical Restraint Preventive Factors
Table 2:
Background Data
Table 3:
Applied Methods of Coercion
Table 4:
Physical Coercion per 100,000 Inhabitants in Denmark and Norway
Table 5:
Ranking of Coercive Measures With Respect to Perceived Intrusion
Table 6:
Effects of Potential Mechanical Restraint Preventive Factors on the Annual
3
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
Number of Mechanical Restraint Episodes
Table 7:
Differences in the Effects of Potential Mechanical Restraint Preventive
Factors on the Annual Number of Mechanical Restraint Episodes in Denmark
and Norway
Appendix A:
Appraisal, Grading, and Combining the Recommendations of the Mechanical
Restraint Preventive Factors
2.4
List of Symbols and Abbreviations
B: Estimate of regression coefficient
n/No: Number
χ2: Chi square
N.a.: No available information
CI: Confidence interval
NICE: National Institute for Health and
Clinical Excellence
DRPS: Danish Reference Programme
Secretariat
Pearson’s r: Pearson´s correlation coefficient
Δ: Difference
p: Probability value
EPSO: European Platform of Supervisory
Organizations
ERM: Early Recognition Method
P.n.: Pro necessitate (as needed)
Exp: Exponentiated
QICC: Corrected Quasi Likelihood under
Independence Model Criterion
GEE: Generalized Estimating Equations
RCT: Randomised controlled trial
IM: Intramuscular injection
SIGN: The Scottish Intercollegiate
Guidelines Network
Ken, b: Kendall’s Taub
SOI: Second Order Interaction
m2: Square meter
UEMS: Union Européenne des médicins
Spécialistes (Psychiatric Section of the
European Union of Medical Specialists)
MERGE: Method for Evaluating Research
and Guideline Evidence
WHO, ICD-10: World Health Organization,
International Classification of Diseases, 10th
version
QIC: Quasi Likelihood under Independence
Model Criterion
MR: Mechanical restraint
2.5
Key Definitions
Mechanical restraint (MR): The use of restraining straps, belts or other equipment to restrict
movement (1).
Coercion: The action of making somebody do something that they do not want to do (2).
4
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
Restraint: The use of physical force to control somebody who is behaving in a violent way (2).
Physical restraint/Holding: Physically holding the patient, preventing movement (1).
Seclusion/Isolation: Isolated in a locked room (1).
Time out: Patient asked to stay in room or area for period of time, without the door being locked
(1).
Forced admission: An involuntary admitted patient (3).
Forced compulsory retention: Forced compulsory retention of a voluntary admitted patient (4).
Forced treatment: An involuntarily treated patient, normally by antipsychotic medications (3);
sometimes called forced medication/long period (4).
Forced acute tranquillising medication/IM medication: Intramuscular injection of sedating drugs
given without consent (1); sometimes called forced medication/short period (4).
Constant observation/Person-to-person-/face-to-face observation: An increased level of
observation, of greater intensity than that which any patient generally receives, coupled with
allocation of responsibility to an individual nurse or other worker. Constant: within eyesight or arms
reach of the observing worker at all times (1). This type of measure is registered as a coercive
measure, in Denmark, if it is involuntary and prolonged for more than 24 hours (5).
Unit: The smallest organisational collection of beds, led by a clinical nurse manager.
3 Summaries in Danish and English
3.1
Summary in Danish (Dansk Resumé)
Tvangsfiksering af psykiatriske patienter indlagt på psykiatrisk afdeling er et voldsomt indgreb i
den enkelte patients autonomi og kan medføre både fysiske og psykiske skader. Det kan dog i
særlige situationer være nødvendigt blandt andet for, at beskytte patienten selv, medpatienter eller
andre. En sådan situation kan for eksempel opstå hvis en indlagt patient er meget aggressiv,
voldelig, selvskadende eller suicidal truet.
Selvom også længerevarende tvangsfikseringer udføres i henhold til den danske lovgivning,
understregede Den Europæiske Komité for Forebyggelse af Tortur (The European Committee for
the Prevention of Torture and Inhuman or Degrading Treatment or Punishment) i rapporter fra
5
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
2002, 2008 og 2014 at, tvangsfiksering af psykiatriske patienter flere dage i træk, ikke har nogen
behandlingsmæssig berettigelse og må beskrives som mishandling/fejlbehandling.
Der er bred enighed om, at anvendelsen af fysisk magtanvendelse herunder tvangsfiksering i
behandlingen af psykiatriske patienter bør mindskes mest muligt, men hvordan dette skal gøres i
praksis, hersker der usikkerhed om. Evidensen på området er stigende, men der mangler fortsat
sikker evidens. Ingen studier har undersøgt hvilke faktorer, der mest effektivt forebygger
anvendelse af tvangsfiksering i praksis i Danmark og Norge.
Det overordnede formål med denne afhandling er at generere viden om ikke-medicinsk
forebyggelse af tvangsfikseringer. Afhandlingen består af fire individuelle studier: Først
gennemførtes et systematisk review af den internationale forskningslitteratur for at identificere
evidente og effektive faktorer (forhold og interventioner), der kunne reducere antallet af
tvangsfikseringer. Formålet var at skabe grundlag for at udvikle et spørgeskema med henblik på at
belyse, i hvilken grad formodede forebyggende faktorer var til stede i de psykiatriske afsnit, som
indgik i afhandlingens studie 3 og 4. Dernæst blev psykiatrilovgivning og anvendelse af tvang i 11
europæiske lande beskrevet og sammenlignet i samarbejde med Sundhedsstyrelsen. Resultaterne
dannede grundlag for udvælgelse af et egnet andet europæisk land med sammenlignelige forhold
som kunne indgå i afhandlingens 3. og 4. studie. Afhandlingens 3. og 4. studie var baseret på en
multicenterspørgeskemaundersøgelse, hvor data blev indsamlet fra lukkede psykiatriske afsnit i
Danmark og Norge for at belyse i hvilken grad de enkelte tvangsfikseringsforbyggende faktorer var
til stede i afsnittene og antallet af tvangsfikseringer det forgange år. Formålet for det 3. studie var, at
undersøge hvorvidt tilstedeværelse af formodede tvangsfikseringsforebyggende faktorer i et afsnit
var associeret med mindre anvendelse af tvangsfiksering. I afhandlingens 4. studie blev data
analyseret med henblik på at identificere, om nogle af de formodede forebyggende faktorer
muligvis kunne forklare forskellen i antallet af tvangsfikseringer mellem Danmark og Norge.
Der blev identificeret tre forebyggende faktorer, som var signifikant associeret til et lavt antal
tvangsfikseringer i Danmark og Norge: Obligatorisk review af tvangsfikseringsepisoder (64 %
færre tvangsfikseringer), Patient involvering (58 % færre tvangsfikseringer) og Crowding (46 %
færre tvangsfikseringer). Derudover blev identificeret fem faktorer, der havde konfunderende effekt
(reducerede forskellen mellem landene), disse kunne være en del af forklaringen på, hvorfor
Danmark anvendte 92 % mere tvangsfiksering end Norge. De fem var: Personalets
grunduddannelses niveau (51 % af effekten), Anvendelse af afløsnings personale (17 % af
6
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
effekten), Arbejdsmiljø (15 % af effekten), Andelen af personaler per patient (11 % af effekten) og
Identifikation af patientens krise-triggere (10 % af effekten).
Resultaterne har uddybet vores viden om hvordan specifikke faktorer reducerer antallet af
tvangsfikseringer. De er ikke identificeret ved gennemførelse af randomiserede kliniske studier, og
selv om nogle svagheder findes i studierne, blev spørgeskemaet udviklet på en grundig måde, der
blev justeret for flere mulige konfunderende faktorer i analyserne, og lignende resultater er fundet i
tidligere forskning fra andre lande. Derudover er der ikke noget, der tyder på, at de fundne faktorer
kan have negative effekter, snarere kunne det tænkes, at den mulige positive effekt, faktorerne har
på forebyggelse af tvangsfiksering, kunne være et udtryk for en generel styrkelse af pleje- og
behandlingsmiljøet. Det anbefales derfor, yderligere at undersøge effekten af at implementere:
obligatorisk review, patient involvering, mindre crowding, højere grunduddannelsesniveau blandt
personalet, anvendelsen af færre vikarer, et bedre arbejdsmiljø, højere antal personaler per patient
og identificering af patienters krise triggere, i praksis i Danmark og Norge.
3.2
Summary in English
Mechanical restraint (MR) is a major infringement on the psychiatric patient’s autonomy. MR can
cause physical and mental harm but may be necessary, e.g. to avoid putting an individual’s health at
risk. The nursing staff is tasked with protecting the life and health of not only the individual patient
but also other patients and relatives. A situation can occur in which staff is obligated to use force
and occasionally MR, e.g. if a patient is very aggressive, violent, self-destructive or suicidal.
Although MR is legal, the European Committee for the Prevention of Torture and Inhuman or
Degrading Treatment or Punishment concluded, in two reports from 2002, 2008, and 2014 that no
medical justification exists for applying instruments of physical restraint to psychiatric patients for
days and that doing so amounts to ill treatment.
Although the number of MR episodes should be reduced as much as possible, how this goal should
be accomplished is quite unclear. Despite the growth in available research in the area decisive
evidence is still lacking. No studies have investigated which of the many MR-preventive factors are
the most effective in practice, in Denmark and Norway.
Therefore, the overall objective of this thesis was to generate knowledge of non-medical MRprevention. The four studies that contributed to this objective had separate purposes. First, a
systematic review of international research papers was conducted to identify evident and effective
MR-preventive factors; this review served as a basis for developing a questionnaire examining the
degree to which MR-preventive factors have been implemented in psychiatric units and the
7
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
numbers of MR episodes in those units. Second, a comparative investigation of European countries
was conducted to identify a country comparable to Denmark to include in the cross-country
questionnaire survey. Third, the collected questionnaire data were analysed to identify the
associations between the MR-preventive factors and the number of MR episodes. Finally, the data
were analysed to identify if the MR-preventive factors could explain the difference in the number of
MR episodes between Denmark and Norway.
Three MR-preventive factors were significantly associated with a low frequency of MR episodes in
Denmark and Norway: a mandatory review of MR episodes (64% fewer MR episodes), patient
involvement (58% fewer MR episodes), and crowding (46% fewer MR episodes). Further, we
identified five MR-preventive factors with confounding effects (reducing the difference between
countries), which may explain in part why Denmark used 92% more MR compared with Norway.
These factors included: staff education (51% of the effect), substitute staff (17% of the effect), work
environment (15% of the effect), patient-staff ratio (11% of the effect), and identification of
patients’ crisis triggers (10% of the effect).
These results have increased our understanding of the ability of specific MR-preventive factors to
reduce the number of MR episodes in Denmark and Norway, thereby generating knowledge in the
field of MR-prevention. These findings have not been identified via randomised controlled trials
(RCTs), and although some biases could be present, the questionnaire was thoroughly developed to
include several potential confounders. Furthermore, similar results have been demonstrated in
previous international studies. These factors are not likely to have adverse effects on the patients or
staff. Rather, the potential positive effects of these factors on the prevention of MR episodes may
reflect a general strengthening of the care and treatment environments. Therefore, further
investigation into the effects of implementing the following within Danish and Norwegian practices
is recommended: mandatory review, patient involvement, less crowding, higher staff education, less
substitute staff use, better work environment, increased number of staff per patient, and the
identification of the patient’s crisis triggers.
4 Introduction
In Denmark, MR can legally be performed, e.g. when psychiatric inpatients pose a risk to
themselves or to others (6). Other countries do not allow the use of MR: forexample, only the use of
seclusion and holding (physical restraint) is allowed (except in exceptional circumstances in Special
Hospital environments) in the United Kingdom. Thus, the use of MR differs greatly across Europe
8
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
and the rest of the world. The practical procedure is primarily prescribed by a psychiatrist, is
performed by nursing staff and involves using leather or fibre belts to secure the patient to a bed,
occasionally with additional straps used around the wrists and ankles.
MR using leather belts has been used in Denmark since, at least 1870, when the use of a
“straitjacket” was abolished (7). Reiter described the use of MR in 1927 (translated by the author):
Of restraints, the belt (ed. MR) is especially used; this is an upholstered girth, that can
be locked around the patient … and secured to the bed … It is only used when other
measures fail and only after a doctor’s prescription. (7)
Unlike most other countries, the use of seclusion is illegal in Denmark. In 1901, Professor Knud
Pontopidan argued (translated by the author):
These (ed. chains and straitjackets) were abandoned from the asylums
armamentarium long ago. However, the medical profession has first achieved its goal
in this area, by abandoning the remaining mechanical restraints, which represents
themselves in the closed cell. The future solution must involve consistently combating
cell treatment. (8)
In 1985, the first legislation (9) on the use of specific types of restraint was published, and seclusion
was finally abandoned, except in a special high security department (Sikringen).
In Denmark other types of coercion can legally be used for psychiatric patients, including forced
admissions/compulsory forced retention, forced treatment, forced acute tranquillising medication,
holding, person-to-person observation, follow-up after discharge, mail examination, patient rooms,
personalised alarm systems, and protective MR (6). Legislation stipulates that the least intrusive
type of coercion must be used only after trying everything possible to avoid using coercion. The
most intrusive coercive measures used in Denmark are: forced admission/compulsory forced
retention, then MR, forced treatment, forced acute tranquillising medication, and holding, and
finally person-to-person observation (10). Danish legislation follows the United Nations Principles
for the protection of persons with Mental Illness and the improvement of Mental Health Care (11).
Thus, as most European Countries also follows these principles, which do not describe the
intrusiveness of the different types of coercion, individual countries likely defined them based on
their own interpretation of human rights, as influenced by their historic– and cultural development.
In Denmark, MR is considered the most intrusive intervention for controlling aggressive or selfmutilating/suicidal inpatients in psychiatric units.
9
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
According to the Danish Mental Health Act, the following conditions must be present to legally
initiate MR (translated by the authors):
Mechanical restraint may be used only when necessary to prevent a patient from
1. exposing their body or health or the body or health of others to danger,
2. pursuing or grossly molesting fellow patients in any way, or
3. committing significant acts of vandalism. (6)
The same conditions must be present to initiate holding. If a patient is very agitated, forced acute
tranquillising medications can be used. The same conditions must be present in many other
countries to initiate MR, seclusion, holding, or forced acute tranquillising medication (10). The
central concept is danger towards self or others, which is the most common reason for using
coercive interventions towards psychiatric patients behaving in an aggressive or selfmutilating/suicidal maner. Thus, although the use of MR is legal in many countries, the discussion
is ongoing regarding how often this intervention should be used, given the patients’ right to selfdetermination and human rights in general. Following visits to Denmark, the European Committee
for the Prevention of Torture and Inhumane or Degrading Treatment or Punishment stated that no
medical justification exists for applying instruments of physical restraint to psychiatric patients for
days and that doing so amounts to ill treatment (12-14).
MR exposes the patient to potential physical injuries such as deep vein thrombosis, pulmonary
embolisms, pressure sores, and bone fractures (15-19). For most patients, MR also involves
negative psychological effects: feeling helpless, angry, trapped, sad, fearsome, unpleasant, or
offended. Individual patients often regard the use of MR as unjust or even as a punishment (20-24),
in the worst case developing long-term trauma and possibly features of post-traumatic stress
disorder (22-24). In addition to affecting the individual patient, the use of MR has a negative effect
on the atmosphere, care, and treatment of the whole unit (20;21). These negative consequences
appear inconsistent with health care providers’ basic attitudes regarding “doing good” for patients.
However, strong counter-arguments regarding the use of MR suggest that health care professionals
are obliged to secure and care for the health and life of the patients and other individuals, while
avoiding violence towards fellow patients, relatives, and staff. Some studies indicate that up to 10%
of patients request the use of MR to prevent acting out (4). Overall, enhanced efforts are required to
reduce the frequency (10).
In a textbook on mental health nursing (translated by the author), Jacobsen wrote the following in
1920:
10
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
“Straitjackets”, where the arms were tied to the chest, as used in earlier times, are
not currently used in any mental health hospital, and even the afore mentioned milder
restraints (ed. MR) are used less frequently and will most likely be rendered
superfluous by numerous and careful nursing staff. (25)
This goal has not been reached; instead, the numbers of MR episodes in Denmark have remained
constant over the previous decade (26) (Figure 1).
Figure 1. Mechanical Restraints in Denmark, 2004–2013
The relevant legislation, which was thoroughly
revised in 1989 has been continually updated, with a
Number of Mechanical Restraint Episodes
special focus on efforts to reduce the use of MR.
7000
These efforts have shown no significant effect,
6000
5000
which is consistent with reports in other countries
4000
(27). This finding is most likely because many
3000
2000
factors influence the events that lead to the use of
1000
MR. The factors that influence an individual
0
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
patient’s aggressive or self-destructive behaviour
and hence the frequency of MR use in a psychiatric
Number of Individuals who Experienced Mechanical
Restraint
unit could be related to the patient, unit, staff or
2500
“situational/interactional conditions” (28). As
2000
Bowers (29) describes in the very recently
1500
developed “Safewards Model” on conflict and
1000
containment on psychiatric wards, six domains of
500
originating factors exist: the staff team, the physical
0
2004
2005
2006
2007
2008
2009
2010
2011
2012
Note. The numbers does not include the special high security
department (Sikringen).
2013
environment, outside of the hospital, the patient
community, patient characteristics, and the
regulatory framework. All of these domains give rise
to potential flashpoints, with the capacity to trigger conflict and/or containment, representing
another way to categorise the originating conditions while underpinning the fact that many factors
influence how often coercive measures are used in psychiatric units.
In Denmark the 6,165 MR episodes recorded in 2013 involved 2,084 individual patients with an
average of 3.0 episodes per patient; 14% of these episodes lasted longer than 48 hours. The
distribution of MR episodes across the five regions in Denmark was as follows: Capital, 115 per
100,000 inhabitants; Zealand, 67 per 100,000 inhabitants; South Denmark, 78 per 100,000
11
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
inhabitants; Mitt Jutland, 165 per 100,000 inhabitants; and North Jutland, 101 per 100,000
inhabitants. The highest numbers of MR episodes were found in regions with the largest cities;
however, despite of including only the second largest city, Mitt Jutland had the highest numbers of
MR episodes. A similar tendency was found upon investigating the MR episodes in relation to the
number of psychiatric beds, or the number of psychiatric patients across the regions (26). Other
conditions in addition to the often-seen urban/rural differences (30) must also influence the regional
distribution of MR episodes.
In Denmark in 2008, the average length of a MR episode was 27 hours. The average age of the
patients subjected to MR was 40 years, and the average age of all inpatients was 42 years,
indicating that patients sumitted to MR was younger. More male (58%) than female patients
experienced MR, although men represented 51% of all inpatients. The diagnostic distribution of
patients experiencing MR were (WHO, ICD-10, principal codes): F00-09, 8.5%; F10-19, 15.3%;
F20-29, 46.6%; F30-39, 16.0%; F40-49, 3.9%; F50-59, 0.3%; F60-69, 6.1%; F70-79, 1.6%; F80-89,
0.6%; and F90-99, 0.9%. The diagnostic distribution of all inpatients was as follows: F00-09, 2.4%;
F10-19, 16.1%; F20-29, 31.5%; F30-39, 24.8%; F40-49, 15.2%; F50-59, 0.7%; F60-69, 6.4%; F7079, 0.5%; F80-89, 0.4%; and F90-99, 1.2%. Thus, the patients experiencing MR were diagnosed
more often with F20-29 and less often with F30-39 or F40-49. Different types of departments had
different diagnostic distributions. For example, in special forensic departments, 46% of the patients
were diagnosed as F20-29 and 12% as F30-39, whereas these frequencies were 31%, and 25% in
acute departments, respectively. In 2008, 22 adult inpatients experienced MR more than 25 times,
comprising 1,150 total MR episodes. Nineteen of these inpatients were woman and 17 were
diagnosed F20-29. Their average age was 30 years, they were admitted in all regions, and they
spend an average of 280 days as inpatients. Thus, few patients experience numerous MR episodes,
and whether these patients respond to the same MR-preventive initiatives as other patients is
unknown. These 2008 data originate from the Danish Health and Medicines Authorities Register on
Coercion and the Danish Psychiatric Central Research Register (31).
Between 1999 and 2003, immigrants and refugees experienced more than twice the amount of MR
episodes as Danish-born population did (32) perhaps because the rates of psychosis are higher
among migrants than non-migrants, because family support systems are lacking, or because
language barriers existed between the staff and migrants in the psychiatric units. Although
differences in MR rates are known to exist, the reason for the difference remains unknown. The
same differences regarding regions, diagnoses, genders, departments, the low number of patients
experiencing multiple MR episodes, and ethnicities are found in other countries (33-37).
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MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
More than 30 reviews of the management of agitation, aggression, violence, and coercion (such as
MR, seclusion, physical restraint, and forced acute tranquillising medication) were identified. Ten
of the reviews explicitly included MR, several of them quite recent (38-42), and all of the reviews
described the absence of high-quality research1. No meta-analyses or meta-syntheses2 were
identified. Thus, which preventive interventions are effective and which interventions only appear
to be effective due to favourable study conditions remain unknown.
Physical restraint/holding, constitutes a coercive intervention in itself but is also employed as part
of several other procedures e.g. MR, seclusion, and forced acute tranquillising medication. Thus if
preventive interventions reduces the number of seclusions, forced acute tranquillising medications
or physical restraints, they are likely also effective in reducing MR. After all, each of these
modalities represents a staff management strategy towards aggressive or self-mutilating/suicidal
patient behaviours.
Numerous factors have been recommended to reduce the use of MR, including risk management,
physical environment, and alarm systems, staff attitudes and care alliance. In risk prediction, the
often highlighted issues include antecedents, warning signs, and risk assessments. The training,
education, skills, competencies, and attitudes of the staff who work with psychiatric patients, as
well as the de-escalation methods and techniques, post-incident review, staff environmental factors
(both mental and physical working environment), medication, effective illness and abuse treatment,
effective observation, and physical training have also been considered (43;44).
Although some of these actions have been locally proven to reduce the number of times MR is used
(45;46), national figures have failed to significantly decrease in some countries, e.g., Denmark and
Norway (26;47).
5 Objective
As described in the introduction, MR is presumed to be the most intrusive intervention towards
aggressive or self-mutilating/suicidal psychiatric inpatients in Denmark. MR is considered a highrisk intervention for both patients and staff, and many preventive interventions, mostly non-medical
1
High quality research may comprise the following types: qualitative such as at least one high-quality meta-synthesis,
systematic review, meta-summary, or a body of high-quality evidence; or quantitative such as at least one metaanalysis, systematic review or body of high quality RCTs.
2
A meta-synthesis is similar to a quantitative meta-analysis. Definition: Meta-synthesis “is the bringing together and
breaking down of findings, examining them, discovering essential features, and, in some way, combining phenomena
into a transformed whole” (Schreiber, R., Crooks, D., and Stern, P. N. Qualitative Meta-analysis. Morse, J. M.
Completing a Qualitative Project: Details and Dialogue. 311-326. 1997. Thousand Oaks, Sage).
13
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
in nature, have been suggested in the international literature. Despite political/legislative initiatives,
the number of MR episodes does not seem to be decreasing in Denmark; thus, the overall objective
of this thesis was to generate knowledge of non-medical MR-prevention.
The four studies that contributed to this objective had separate purposes:
Study 1:
Which conditions in nursing and which nursing interventions have been shown
to reduce the frequency of mechanical restraint episodes?
Study 2:
To compare the use of coercive measures on psychiatric inpatients between
Denmark and Sweden, Norway, Finland, Iceland, Belgium, The Netherlands,
United Kingdom, Ireland, France, and Italy, in order to share knowledge and
learn about what other countries do to minimize coercion.
Study 3:
How are presumed MR-preventive factors of non-medical origin associated with
the frequency of MR episodes in Denmark and Norway?
Study 4:
To examine how presumed MR-preventive factors of non-medical origin may
explain the differing number of MR episodes between Denmark and Norway.
6 Design and Methods
To generate knowledge of non-medical MR-prevention, the research was designed in the following
manner:
1. A systematic review of international research papers, combining quantitative and qualitative
research, was conducted to identify evident and effective MR-preventive factors (Study 1).
2. A descriptive comparative investigation, regarding the use of coercive measures in European
countries, was performed to gain knowledge about the use of coercion in other European
countries and to identify a comparable country that uses less MR to be included in the
subsequent questionnaire survey (Study 2).
3. A questionnaire survey based on the results of the review (Study 1) was conducted to
examine the relationship between the number of MR episodes and the degree to which the
MR-preventive factors were implemented in “closed” psychiatric units in Denmark and
Norway (Studies 3 and 4).
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MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
4. Finally, two analytic investigations were conducted to identify the potential associations
between the number of MR episodes and MR-preventive factors (Study 3) and to determine
to what degree the identified MR-preventive factors could explain the different number of
MR episodes between Denmark and Norway (Study 4).
Regarding the systematic review (Study 1), this particular design was chosen because very few
RCTs and no meta-analyses were found. Therefore, searches were not limited to these study
designs. Additionally, some of the areas under investigation could not be covered by quantitative
papers alone. Therefore, a combination of quantitative and qualitative papers into ranked
recommendations was developed to deduce maximal information from the available papers.
The systematic review process was based on the principles outlined by, first, the Danish Reference
Programme Secretariat (DRPS) (48), and the National Institute for Health and Clinical Excellence
(NICE) (43) for the evaluation of the quantitative research, and second, by Sandelowski and
Barroso (49) and Kearney (50) for the evaluation of the qualitative research. The Scottish
Intercollegiate Guidelines Network (SIGN) (51) inspired the process of the combined evaluation of
both qualitative and quantitative research. The combination of principles from the above mentioned
sources was necessary because no one source in itself covered both quantitative and qualitative
research quantification.
The stages of the review process were as follows: developing the scope of the review, drafting
review questions with a clinical focus, and inclusion and exclusion criteria, implementing a search
strategy and search phrases, identifying sources of evidence, carrying out searches, sifting through
the evidence, extracting relevant data from studies meeting both the methodological and clinical
criteria, evaluating the methodological quality using relevant checklists, compiling papers into
relevant evidence tables, interpreting and grading each paper, abstracting interventions,
summarising intervention levels, separately grading the recommendations for the quantitative and
qualitative evidence, and summarising the whole body of evidence.
The scope of the review was to answer the following question: which conditions in nursing and
which nursing interventions have been shown to reduce the frequency of MR episodes? Next,
review questions were developed, e.g. “Do communicative de-escalation techniques prevent MR?”
or “Do specific types of limit-setting prevent MR?” The searched papers included original peerreviewed papers on the care of adult psychiatric inpatients that were physically restrained. Physical
restraints were included in several procedures e.g. MR, seclusion, and forced acute tranquillising
medications; as such, if the preventive factors described in the literature reduces the number of
15
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
seclusions, forced acute tranquillising medications, or holdings, they are likely to be effective
towards MR reductions as well. Papers were excluded if they were reviews, or if they described
interventions and conditions to prevent physical restraint in non-psychiatric inpatient settings,
learning disability settings, nursing homes, or prisons. The papers were obtained from 1998 to April
2009. The searches included English, Danish, Norwegian, and Swedish language citations, all with
English abstracts. A total of 84 key words were used in different combinations and inflections in the
search, e.g. affect, aggression, alliance, coping, debriefing, intervention, and restraint.
The structure of the search strategy was as follows: an overarching strategy for conditions and
interventions across selected databases, a search to identify guidance and reports (for example,
governmental reports, not indexed in the major databases), and topic-specific search strategy on
PubMed. For each condition or intervention, evidence supporting effectiveness or harm was sought.
A manual search was performed in key areas that were not electronically indexed (e.g., PhD thesis),
and the reference lists of the most relevant papers were checked for articles not otherwise found.
Sifting through the evidence was completed in three steps. First, we sifted through the material that
potentially met the eligibility criteria based on the title/abstract. Second, full papers were reviewed
for relevance/eligibility or for vague relevance/eligibility. Third, the papers were critically
appraised checked for quality.
Checklists for evaluating the methodological quality of the papers, and evidence tables for
compiling the studies were gathered (48-50;52-54). Once the individual papers had been assessed
by the author for methodological quality and relevance in terms of the clinical questions, they were
graded according to the levels of evidence. Grading of the quantitative research papers was
conducted as outlined by the DRPS (48). The levels of evidence and grades of recommendation
were developed from the DRPS (48), the Method for Evaluating Research and Guideline Evidence
(MERGE) (54), and SIGN (51). Grading of the qualitative research was performed according to the
levels of complexity in the evidence described by Kearney (50), and the process was inspired by
Sandelowski and Barroso (49), Kearney (50), the MERGE (54), the DRPS (48), and the SIGN (51).
The evidence for each intervention/condition was then compiled into tables. The quantitative and
qualitative grading systems can be found at the end of Appendix A, the different checklists are
available upon request from the author.
The final synthesis was based on consensus decisions by the four authors of Paper 1 and was guided
by the following three questions. Which interventions match the patients’ views and experiences?
16
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
Which interventions have yet to be evaluated in clinical settings? Does the effect of the intervention
seem plausible from a clinical point of view?
The results of the systematic review are displayed in a hierarchy, combining recommendation
grades and effects. The recommendation grade describes the ability of an intervention to exert an
effect by reducing the number of mechanical restraints in the clinical setting—that is not the degree
that such an intervention would reduce the number of mechanical restraints but rather whether the
intervention would reduce the number. This procedure is described in five levels from 1 to 5, with 1
being the best. Accordingly, 1 indicates an intervention that most certainly would have an effect on
the phenomenon (MR), and 5 indicates a high degree of uncertainty as to whether the intervention
would have an impact on or have any relation at all to the phenomenon. Combining the quantitative
and qualitative recommendations was achieved by taking the better of the two. The effect is
considered as effect of the intervention on MR (MR, seclusion, physical restraint, etc.) reductions,
whereas the reduction in the number of MR was divided into five levels from 1 to 5, with 1 being
the best and ranging from 80% to 100% reduction, 2 from 60% to 80%, and so on. The effect of the
intervention was extrapolated from the quantitative papers and combined in the following manner:
with no quantitative papers, the level was set to 5 (0–20% reduction); with one, the level was
transferred directly; with two or more the level was first influenced by the paper with the best
recommendation grade, second by the paper best describing the intervention, and third by a simple
average.
Regarding the comparative investigation into the use of coercive measures in European countries
(Study 2), this particular design was chosen to screen selected European countries based on their
use of coercive measures. This aim was achieved in two ways: first, by reviewing international
reports, research literature, and national registers, and second, by performing a survey that asked
government officials and medical specialists to complete a questionnaire.
Primarily to examine “numbers” on background features and coercive measures, the literature
review covered the legislation and coercive measures used in psychiatry across Europe follows:
forced medication/long period, forced medication/short period, MR, seclusion, holding, time out,
and constant observation. The review was conducted between April and June 2009, with an update
in March 2010, and covered the years from 1999 to 2010. The searches included literature in the
following languages: English, Danish, Norwegian, Dutch, Finnish, and Swedish. The search
strategy was structured as: an overall search for legislation and coercion across selected databases, a
17
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
search to identify registers and reports (e.g. governmental reports not indexed in the major
databases), a topic-specific search on PubMed, and lastly, the reference lists of the most relevant
papers to identify articles not otherwise found. Once the references were retrieved, sifting process
was initiated including a first sift for material that potentially met the eligibility criteria based on
title/abstract and a second sift for the full references that appeared relevant and eligible or in which
the relevance/eligibility was not clear from the abstract. Finally, a third sift allowed for the critical
assessment of the references. The focused search strategy is laid out in Paper 2, Supplementary,
Appendix 1.
The questionnaire survey was primarily developed to gather knowledge on the legislation across the
selected European countries by the two authors and two representatives from the mental health
authorities in Denmark. The questions were based on Danish legislation, and on knowledge gained
from nationwide reports and papers (e.g. Policies and practices for mental health in Europe (55),
including the compulsory admission and involuntary treatment of mentally ill patients - legislation
and practice in EU-member states (56), among other (57-62)). The questionnaire covered legislative
practices in the same areas mentioned earlier in the literature review.
The construction of the questionnaire followed a guide developed by Olsen (63) comprising six
phases: guiding the formulation of the problem, understanding the questions, recalling information,
evaluating contextual effects, editing answers, and conducting tests. The test-retest validation was
primarily internally conducted among the members of the constructed group, but two responders
were asked if they understood and were able to answer the questionnaire.
The respondents included governmental health staff working with mental health issues/legislation,
because they are the most knowledgeable of the mental health legislation in the selected countries.
The questionnaires were sent to the members of the European Platform of Supervisory
Organisations (EPSO), a body that was formed in 1996 to create a network of supervisory
organisations in health care. Additionally, the questionnaire was sent to the members of the
Psychiatric Section of the European Union of Medical Specialists (Union Européenne des médicins
Spécialistes, UEMS), to gain knowledge regarding possible differences between the current
legislation and its translation into practice. These respondents represent medical specialists in
psychiatry from each of the different countries.
An example from the questionnaire can be found in Paper 2, Supplementary, Appendix 2. The
questionnaire survey was administered between May and July 2009. The results are shown as
purely descriptive “raw” data.
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MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
Studies 3 and 4 were designed as a cluster cross-sectional questionnaire survey based on the results
of the review (Study 1). The survey was conducted to examine the relationship between the number
of MR episodes and the degree to which the MR-preventive factors were implemented in “closed”
psychiatric units in Denmark and Norway (Studies 3 and 4).
Norway, which has very similar legislation, was included in the survey to increase the power of the
latter analysis and to strengthen its overall transferability. The following conditions must be present
to legally initiate MR according to the Danish Mental Health Act (translated by the authors):
Mechanical restraint may be used only when necessary to prevent a patient from
1) exposing their body or health or the body or health of others to danger,
2) pursuing or grossly molesting fellow patients in any other way, or
3) committing significant acts of vandalism. (64)
These conditions are consistent with Norwegian legislation (translated by the authors):
Restraints may be used on a patient only when absolutely necessary to prevent him or
her from damaging him/herself or others or to prevent damage to buildings, clothing,
inventory or other things. (65)
Additionally, Norway had a lower rate of physical coercion (MR, seclusion, and physical
restraint/holding) with 29 patients per 100,000 inhabitants experiencing physical coercion compared
with 52 patients per 100,000 inhabitants in Denmark (4). Specifically regarding MR, Denmark had
122 episodes of MR per 100,000 inhabitants compared with 87 episodes of MR per 100,000
inhabitants in Norway in 2007 (66;67). The lower frequency of MR episodes in Norway might
indicate that more effective MR-preventive factors have been implemented in Norway compared
with Denmark or that MR-preventive factors exhibit differing effects between the countries.
In the questionnaire MR is defined as the use of restraining straps, belts or other equipment to
restrict movement (1). Notably, this definition refers only to the MR of adult (18-65 years)
inpatients in psychiatric hospitals and does not refer to the use of MR in prisons or nursing homes.
The MR-preventive factors identified by the literature review (Study 1) were included in an online
questionnaire and sent to the clinical nurse managers (the respondents) to quantify whether they
were implemented in the units. These managers were chosen because they had exclusive access to
the requested information.
The Danish questionnaire was administered between 23 December 2009 and 28 May 2010, and the
collected data pertained to 2008. The Norwegian questionnaire was administered between 29
19
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
October 2010 and 27 January 2011, and the collected data pertained to the previous 12 months,
most of which occurred in 2010.
The study included all psychiatric hospital units in Denmark (n = 87) and Norway (n = 96) that
treated adult inpatients (18-65 years) and used MR for approximately two years prior to the year of
the investigation. MR did occur in Norway in settings other than hospitals; however, given that only
1.5% of recorded MR episodes in 2007 occurred in these settings (67) and that hospitals served as
the primary focus, these units were not included. The special high-security department in Denmark
was excluded due to specific legislation on coercive measures.
If MR was used more than 25 times on the same patient during the investigation period, then the
episodes of MR > 25 were excluded. Chance determined the units to which these few patients were
admitted, but the presence of these patients could significantly affect the MR frequencies of these
units, thereby distorting the results, as described in the introduction. The number of 25 times on the
same patient during one year was chosen after visually examining a graph of MR episodes per
patient in the Danish cohort. The examination showed that the number of times the same patient
experienced MR slowly increased until the point of 25 times, were a rapid increase in times was
found, i.e. extreme cases.
In the development of the questionnaire each MR-preventive factor was “translated” into questions
to identify the degree to which the factor was present in the units. Six factors were not included.
Combined intervention programmes were also omitted because of the complexities in their
measurement and the implications of other factors, e.g. training, work environment, and early
recognition of patient triggers. The following three factors: treatment of substance abuse and
psychosis, pro necessitate (p.n.)/as-needed medication guided by individual patients, and carealliance, were omitted because they were not considered to be measured appropriately by a
questionnaire, leading to the emergence of eventual confounding effects created by the three
factors, was covered by other covariates such as the type of unit, type of bed, number of units
nested in the departments, or number of MR episodes experienced by patients with a forensic
provision. For instance, if care-alliance was associated to the outcome and was poorer between
patients with a forensic provision and the staff, because some are involuntarily admitted for long
periods of time, this effect would be reduced by the covariate, number of MR episodes experienced
by patients with a forensic provision. Finally, two MR-preventive factors: music used as a diversion
or for relaxation, and patients perceived as a resource in their own treatment were omitted, as these
factors were partially covered by other factors, such as activity-based nursing and patient
20
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
involvement. The omitted MR-preventive factors only represented a problem for the later analyses
if they acted as confounders in the association between the other MR-preventive factors and the
outcome; thus, at the same time not associated with one of the covariates making them act as proxy
covariates. The odds for this situation to occur are very small.
Cognitive milieu therapy and patient involvement as well as patient-centred care and patient
involvement were separated into three factors: cognitive milieu therapy, patient-centred care, and
patient involvement. Although patient involvement is part of cognitive milieu therapy and patientcentred care, patient involvement might also occur by itself. These stipulations left; 22 separate
MR-preventive factors to be included in the questionnaire.
The questionnaire was developed by conceptualising and operationalising the MR-preventive
factors. To increase validity and reliability the Question Appraisal System QAS-99 (68) was utilised
to identify problems within the questionnaires, including the cognitive processes inherent in the
question-answering process. The construction and pre-testing of the questionnaire involved an
eight-step appraisal of each item (QAS-99), as follows: reading, instructions, clarity, assumption,
knowledge/memory, sensitivity/bias, response categories, and others. The pre-test was conducted by
creating a cognitive-test protocol including probes for each item. The probes covered the
aforementioned eight steps and comprised the following types: general, specific,
understanding/interpretation, safety, paraphrasing, and memory. The pre-test was performed by
cognitively interviewing (69) four clinical nurse managers individually with concurrent probing
(70), in which verbal probes were immediately asked after a question. This protocol led to revision
of seven questions that were subsequently pre-tested in a group interview.
Data collection, administration, processing, error identification, and electronic data file creation
(63;71), were conducted using the electronic web-based survey system Enalyzer Survey Solution,
Version 2010 (Enalyzer A/S, Copenhagen, Denmark).
The questionnaire was checked for test-retest reliability by asking three clinical nurse managers to
answer the questionnaire a second time after a three-month interval (the respondents were instructed
not to check their previous answers). The estimated mean correlation between all of the first and
second answers was reasonable (Kendall’s Taub [Ken, b] = .75). With regard to the Norwegian
portion of the study, the questionnaire was translated and retranslated by the author and then
checked by two healthcare professionals who were familiar with the subject. A pre-test was
conducted to test face validity through cognitive interviews of seven clinical nurse managers. This
test led to the revision of eight questions, mostly due to imprecise translations. Moreover, one
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MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
question was added to the questionnaire due to different staff competencies, as psychologists in
Norway are partially responsible for their patients’ treatment, which was not the case in Denmark at
that time.
Later, the outcome variable (i.e., the number of MR episodes) was re-examined. This procedure was
necessary due to confusing wording of a heading in the Danish questionnaire and the lack of precise
numbers regarding the Norwegian patients who experienced MR more than 25 times (14 answer
categories instead of the actual number were provided, causing imprecise exclusion). Reexamination was accomplished by contacting all of the clinical nurse managers in Denmark and
four of the clinical nurse managers in Norway. The respondent rate was 94%, and the results
lowered the overall frequency of MR by 3.2%. A high correlation coefficient (Ken, b =.89) was
found between the two answers, revealing that the confusing heading and the categorisation error
did not have an important effect.
A description of how the 22 dichotomised MR-preventive factors were measured can be found in
Papers 1 and 2.
As described in the introduction, several conditions might influence how much MR is used. These
conditions include geography (region), type of unit (department), ethnicity other than
Danish/Norwegian, gender, diagnoses, and the small number of patients experiencing many MR
episodes. In the later analyses unit size, patient flow, bed occupancy, type of bed, reason for the
MR, country, and forensic provision, could also possibly have an influence on how often MR is
used. The specific background variables included as covariates in the later analyses and the
dispersion of MR episodes between the categorised background variables in the subsample (data
from the questionnaire survey) can be found within Papers 3 and 4.
Finally, two analytic investigations were conducted, the first, to identify the potential associations
between the number of MR episodes and the MR-preventive factors (Study 3), and the second, to
determine the degree to which the identified MR-preventive factors could explain the different
numbers of MR episodes between Denmark and Norway (Study 4).
The first analytic investigation was conducted by analysing the data from the questionnaire to
identify potential associations between the number of MR and the MR-preventive factors (Study 3).
Data analyses were conducted in four steps. We first examined how the factors were individually
associated with the number of MR episodes (Model 1), and then how the factors were associated
with the number of MR episodes, using a model with all factors included (Model 2). To eliminate
22
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
multicollinearity and the chance that important effects may hide each other from Model 2, a third
model was constructed by a forward factor-selection procedure, in which the most significant
factors were included stepwise until the corrected quasi-likelihood under the independence model
criterion (QICC) value began to rise, denoting no further improvement for the model (Model 3). All
of these models were adjusted for potentially confounding variables. Additionally, we adjusted for
the nesting of units in departments — 17 departments containing two units each and three
departments containing three units each — by a Generalised Estimating Equations (GEE)
technique. Finally, we analysed the correlations among the factors by Pearson’s correlation
coefficient, adjusted for department, to explore multicollinearity and to justify a reduction of Model
2. In Models 1–3, linear regression was used to assess the associations between the number of MR
episodes and the chosen factors. To stabilize the variance, the outcome was logarithmically
transformed. Hence, the regression coefficients are reported back-transformed (exponentiated;
exp[B]) and must be interpreted multiplicatively. Hence, because the preventive factors were
dichotomized, a regression coefficient exp(B) indicates the average number of times MR increased
for units in which this factor was present compared with units in which this factor was absent. To
account for multiple testing, a p value < .01 was chosen to indicate significance.
The second analytic investigation was conducted by analysing the data from the questionnaire to
determine the degree to which the identified MR-preventive factors could explain the different
number of MR episodes between Denmark and Norway (Study 4). The data analyses were
conducted in five steps. First, the difference in the frequency of MR episodes between the countries,
was analysed. Second, how the factors were individually associated with the number of MR
episodes in Denmark and Norway was separately investigated. Third, we assessed whether an
interaction between MR-preventive factors and the country (second order interaction, SOI) existed.
Fourth, the difference in the prevalence of MR predictive factors between the two countries was
probed using Pearson’s chi-square test (χ2). Fifth, the confounding effects of the MR-preventive
factors, i.e., the difference in the effect of the country in models with and without the corresponding
MR-preventive factor expressed as a percentage (∆ exp[B]); a percentage greater than 10% was
chosen to denote a significant difference. Linear regression was used to estimate the associations
among the frequency of MR episodes, countries, and MR-preventive factors. To stabilise the
variance, the outcome was logarithmically transformed. Hence, the regression coefficients are backtransformed (exponentiated; exp[B]) and should be interpreted multiplicatively. Because the
preventive factors were dichotomised, the regression coefficient exp(B) indicates the average
number of times the MR increased for the units in which a factor was present compared with the
23
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
units missing this factor e.g., result of exp(B) = 0.42 should be interpreted as 0.42 times the average
number of MR incidents without the MR-preventive factor or 58% fewer MR episodes that occur
with the MR-preventive factor than would without it. Except for the first analysis, in which the
dichotomised variable was the “country,” the regression coefficient exp(B), indicates the difference
between the countries in the average number of MR episodes. Further, all models, except the fourth
set of analyses (χ2-test), were adjusted for background variables. Adjustments were made for the
nesting of units in the departments (17 departments contained two units each and three departments
contained three units each) using a GEE technique. To account for multiple testing, a p-value < .01
was chosen to indicate significance.
All analyses were performed using IBM SPSS Statistics for Windows, Version 19.0 (released in
2010; Armonk, NY, IBM Corp.).
7 Results
7.1
Summary of Results, Study 1
Mechanical Restraint – Which Interventions Prevent Episodes of Mechanical Restraint? – A
Systematic Review.
This systematic literature review was conducted to identify which conditions in nursing and which
nursing interventions have been shown to reduce the frequency of mechanical restraint episodes.
The search yielded a total of 2,885 papers. After three sifts, a final number of 59 papers were
included in the further review process. Of these, 48 papers were quantitative and 11 papers were
qualitative (a table presenting the appraisal, grading, and combination of the recommendations
regarding the MR-preventive factors can be found in Appendix A).
Upon hierarchically displaying the preventive factors (Table 1), the implementation of cognitive
milieu therapy e.g. through patient involvement and empowerment; combined intervention
programmes e.g. patient participation, patient education, staff education, programmatic changes,
high-level administrative endorsement, cultural changes, and data analysis; and implementation of
patient-centred care with a high degree of patients´ positive involvement in their own care reduces
the number of mechanical restraint episodes. These are among the three highest ranking MRpreventive factors.
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MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
Table 1. Hierarchy of Mechanical Restraint Preventive Factors
Rank
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Preventive factor (reference)
Implementation of cognitive milieu therapy reduces the number of mechanical restraint episodes, among other things
through patient involvement and empowerment (72;73)
Combined intervention programmes are effective in avoiding mechanical restraints, for example, patient participation,
patient education, staff education, programmatic changes, high-level administrative endorsement, cultural changes, data
analysis, etc. (45;46;74-76)
Implementation of patient-centred care with a higher degree of patients´ positive involvement in their own care reduces the
number of mechanical restraint episodes (73;77;78)
The identification of the patients’ crisis triggers unique calming techniques and decisions on specific crisis interventions
early in the admission procedure, thereby reducing the number of mechanical restraints (79-82)
Introduction of validated risk assessment systems including suggestions of care interventions reduce the number of
mechanical restraints (83-85)
Effective treatment of substance abuse and psychosis reduces the number of mechanical restraint episodes; the treatment of
mental illnesses is also described elsewhere in the review (73;77;78;86)
Mandatory review from qualified clinical experts, for example, as post-incident review minimizes the number of
mechanical restraint episodes (87;88)
Better staff training reduces the number of mechanical restraints (longer duration of the training, more staff participating,
use of different and involving education methods, higher quality of the content and greater diversity of the topics, for
example, legislation, crisis management, physical intervention strategies, antecedents, warning signs, de-escalation
techniques etc.) (20;79;89-96)
Staff attitudes such as positive care for the patients, respect, collaboration, communication, humanism, empathy and less
control and involuntary procedures, reduce the number of mechanical restraints (1;81;95;97-102)
Higher patient-staff ratio reduces the number of mechanical restraints (103;104)
The higher educated staff, the fewer episodes of mechanical restraints (90;93;95;105;106)
The more experienced staff, the fewer episodes of mechanical restraints (90;93;95;105;107;108)
If nurses change their focus from considering the patient as deviant to being a resource in their own treatment it would
decrease the number of mechanical restraint (109)
Early and adequate administration of oral p.n. medication guided by the individual patients´ problems, medication
experiences, and preferences leads to fewer mechanical restraint episodes (80;81;97;110;111)
Debriefing, defusing and crisis intervention minimize the number of mechanical restraint episodes (20;79;105;112)
Patients´ response to rules can be positive and lead to fewer cases of mechanical restraint. For instance, if staff helps
patients to understand not only the rules, but also the rationale for the presence of such rules. If the staff manages to make
patients understand that the rules are imposed out of concern for their welfare, then patients may be less reluctant to
following these rules (81;100-102;113)
Activity-based nursing interventions e.g. physical activities are effective in avoiding mechanical restraints (81;114)
Several mental and physical working environmental factors influence positively the number of mechanical restraints, for
example, good management as a high degree of order, organization, or support; adequate staffing, psychiatric training,
rotation, education, no crowding, emergency backup, etc. Several of these factors are described elsewhere in the review
(20;115-118)
Less crowding, for example, less stimuli, less environmental stress and more personal space decrease the number of
mechanical restraints (81;119)
Higher regular staff and lower substitute ratio reduce the number of mechanical restraints (20;95;120)
Staffs´ opposition towards mechanical restraint, due to the perception that mechanical restraint is ethically problematic,
decrease the number of mechanical restraints (121;122)
Alarm systems, for example, video surveillance and radio systems and well trained response teams, reduce the number of
mechanical restraints (123)
Better care-alliance between patients and the nursing staff reduces the number of mechanical restraints (104)
Communication especially communicative de-escalation reduces the number of mechanical restraint episodes (124)
Well-maintained and familiar surroundings reduce the number of mechanical restraints (125)
Music as diversion and relaxation before and after mechanical restraint reduces the number of mechanical restraint episodes
(126)
Separation of acutely disturbed patients reduces the number of mechanical restraint episodes (81)
Note. Rank refers to the number in the hierarchy where 1 is highest/best. p.n. = pro necessitate (as needed).
25
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
The development of the combined recommendation grading system, which describes a single,
combined grade for the quantitative and qualitative evidence, allowed studied MR-preventive
factors to be displayed within a
Figure 2. Effect and Recommendation Grade Matrix
matrix of the effect and
Effect
recommendation grades, in
1
1
2
2,3
which the recommendation
grade and effect were weighted
as equally important. The
3
6,7
4
9,10
8
recommendation grade
describes the evidence
4
5
5
regarding a specific
14,15,16,17,
18,19,20,21, 11,12,13
22,23,24,25,
26
27
5
4
3
intervention level of scientific
“truth” or its potential for
2
1
clinical application on a scale
Recommendation grade
from 1 to 5, for which 1 is the
Figure 2. The numbers in the matrix refer to a specific factor (the fist number in the hierarchy of the mechanical restraint
preventive factors). Recommendation grade describes the evidence regarding a specific intervention level of scientific “truth”
or its potential for clinical application, from 1 to 5, where 1 is the highest/best. Effect refers to the reduction in the number of
mechanical restraints, from 1 to 5, with 1 being the best, from 80% to 100% reduction, 2 from 60% to 80%, etc.
highest/best. The effect refers
to the reduction in the number
of MR episodes, from 1 to 5, e.g. with 1 representing an 80% to 100% reduction, 2 a 60% to 80%,
and so on (Figure 2).
No MR-preventive factors reached the highest degree of recommendation combined with the
highest level of effect. One MR-preventive factor reached the highest level of effect, with a
decrease in MR use of 87%; however, it received a recommendation grade of only 3. Another factor
had a recommendation grade of 2 but a decrease in MR use of only 27%.
Almost no papers described negative or harmful effects for patients or staff such as increased
numbers of staff or patient injuries or increased use of other types of more intrusive coercive
measures. Of the 59 papers included in this review, one study, by Bowers (89) identified that
attending briefer update courses in physical restraint/holding techniques, triggered small short-term
rises in the rates of physical aggression; however, these results are consistent with a threshold
effect, indicating that once adequate numbers of staff have been trained, further training keeps
incidents rates low. One study by Khadivi (74), detected an increase in assaults on patients and staff
after implementing an intervention that included staff education, early recognition, debriefing, and
post incident review. Future initiatives are suggested to be followed by safety monitoring and staff
training in the management of violent patients.
26
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
Corrigendum: Unfortunately, a few minor reference errors were identified after publication; thus, a
corrigendum was published (Paper 1, at the end).
7.2
Summary of Results, Study 2
Coercion within Danish Psychiatry Compared with 10 Other European Countries.
This investigation was conducted to compare the use of coercive measures on psychiatric inpatients
between Denmark and Sweden, Norway, Finland, Iceland, Belgium, The Netherlands, United
Kingdom, Ireland, France, and Italy, to share knowledge and learn about what other countries do to
minimise coercion.
All members of UEMS responded to the questionnaire, but only a few members of EPSO provided
answers.
Most of the background data (Table 2) and the physical coercion data (Table 4) were retrieved from
the literature review and collected from several sources, including national registers,
governmental/specialist reports, and research papers (55;57;59-61;66;67;127-133). Data on legally
applied coercive measures (Table 3) and the perception of intrusiveness (Table 5) were retrieved
from the questionnaire.
For the purpose of this thesis, Norway was included in the later described research (Studies 3 and
4), and the results from Denmark and Norway are shown.
Table 2 shows the background data from Denmark and Norway.
Table 2. Background Data
Psychiatric beds per 100,000 inhabitants (55) (2007)
Number of forced admissions per 100,000 inhabitants (56;59;131) (1999-2001)
Mean length of stay in days (55;57) (1998 and 2007)
Forensic psychiatric beds per 100,000 inhabitants (60;61) (2002-2007)
Psychiatric beds in jails per 100,000 inhabitants (60;61) (2002–2007)
Year of last revision of the psychiatric code (Questionnaire survey - 2009)
National register for coercion (Questionnaire survey - 2009)
Psychiatrists per 100,000 inhabitants (55) (2007)
Nurses working in Mental Health Care per 100,000 inhabitants (55;132) (2007)
Denmark
Norway
61
70
30
6.6
0
2006
X
11
64
119
135
29
0
0
2006
X
16
N.a.
N.a.: No available information. Year: The available data were recorded from 1998 to 2008. The numbers of forced admissions: Denmark: 2000,
Norway: 2001. Mean length of stay was in Denmark from 2007 and Norway 1998. Mean length of stay: The median number of days in mental
hospitals and community-based psychiatric inpatient units. Denmark: The number of forced admissions includes forced compulsory retention of
voluntarily admitted patients; the number on forced admissions alone would be 34. “Nurses working in Mental Health Care” refers to all nurses, the
number of specialized nurses was 9 (55;132). The length of stay is only from community-based psychiatric inpatient units.
The number of psychiatric beds was almost twice as high per 100,000 inhabitants in Norway (61,
119). The number of forced admissions was also almost twice as high per 100,000 inhabitants (70,
135). The mean length of stay in days was the same (30, 29). Norway had no specialised psychiatric
forensic beds (6.0, 0), and neither Denmark nor Norway had psychiatric beds in jails. The last
27
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
revision of the psychiatric code was the same (2006) in 2009, later revisions has since been
published. Both Denmark and Norway had a national register on coercion, although Norway only
collected complete data some years. Denmark had fewer psychiatrists than Norway per 100,000
inhabitants (11, 16). The number of nurses working in mental health care in Norway was
unavailable.
Table 3 shows the applied methods of coercion from the two countries.
Table 3. Applied Methods of Coercion
Forced medication/long period
Forced medication/short period
Mechanical restraint
Seclusion/isolation
Physical restraint/holding
Time out
Constant observation
Are other types of coercion used
Denmark
Norway
X
X
X
X
X
X
X
X
X
X
X
X
X
Blank: Coercive measures were not in use, allowed, or perceived as a coercive measure in the country. Denmark: If patients complained about the use
of forced medication, it would give 2-3 weeks delayed effect before medication could be initiated. During mechanical restraint, constant observation
was required. Seclusion had only been allowed since 2005 and only in a particularly high security department for extraordinarily dangerous
psychiatric patients. Physical restraint was only used few minutes in connection with other coercive measures. Time out was not regarded as coercion.
Constant observation as a coercive measure was first reported if it was prolonged more than 24 hours. Norway: Seclusion was only allowed in acute
situations and was not to be used if patients were under 16 years. Time out was not regarded as coercion. Constant observation was first regarded as a
coercive measure after 12 to 24 hours.
Denmark and Norway applied the same methods of coercion, except for seclusion, which was only
allowed in a special high security department in Denmark.
Table 4 shows the usage of the three most frequent physical coercive measures: MR, seclusion, and
physical restraint/holding (physical restraint/holding not as part of MR or seclusion, but as the only
coercive measure).
Table 4. Physical Coercion per 100,000 Inhabitants in Denmark and Norway
Mechanical restraint
Seclusion/isolation
Physical restraint/holding
Denmark
Norway
34
0
18
21
2
6
Denmark: 2007. The numbers included: geronto-, child/adolescent, and forensic psychiatry (66). In Denmark, it was possible for the patients to be
subjected to voluntary mechanical restraint, which occurred in 10% of all incidents. Norway: 2007. The numbers included: geronto-, child/adolescent,
and forensic psychiatry (67).
In 2007, Denmark used more MR and physical restraint/holding than Norway (34, 21 and 18, 6).
Norway used more seclusion/isolation than Denmark, but no numbers from the Danish high
security department were available.
Table 5 shows the ranking of the coercive measures with respect to perceived intrusion in the two
countries.
28
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
Table 5. Ranking of Coercive Measures With Respect to Perceived Intrusion
Forced medication/long period
Forced medication/short period
Mechanical restraint
Seclusion/isolation
Holding/physical restraint
Time out
Constant observation
Mechanically restraint ambulatory
Denmark
Norway
5
4
7
6
3
1
2
8
8
7
6
4
3
1
2
5
Forced medication/short period: Was defined as medicine given against the patient’s will in an emergency (not medical treatment for a longer time
according to treatment plan). Forced medication/long period: Was defined as medicine given against the patient’s will, as treatment (medical
treatment for a longer time according to treatment plan). Mechanically restraint ambulatory: Was defined as the use of restraint devices, which allow
patients to be out of bed and to walk around.
The degrees of intrusion for the coercive measures were perceived differently in the two countries,
In Denmark ambulatory MR, MR, and seclusion/isolation are perceived as the most intrusive
measures, whereas forced medications were perceived as the most intrusive in Norway.
7.3
Summary of Results, Study 3
Mechanical Restraint in Psychiatry: Preventive Factors in Theory and Practice. A Danish–
Norwegian Association Study.
In this study, a cross-sectional questionnaire was used to identify how the presumed MR-preventive
factors of non-medical origin were associated with the frequency of MR episodes in Denmark and
Norway.
The responding and non-responding clinical nursing managers in the units were equally distributed
across the countries (overall response rate = 49%). Data from 43 and 47 units were included in
Denmark and Norway receptively. The reasons for non-response were indicated by the clinical
nurse managers as “change of clinical nurse manager” (n = 9), “lack of personal resources to
accomplish the task” (n = 7), sick leave (n = 5), inability to remember/identify the number of MR
episodes (n = 5), and lack of belief that this type of research was beneficial (n = 1). The remaining
63 nurse managers did not provide a reason.
The respondents reported 2,361 MR episodes in Denmark and 1,017 MR episodes in Norway
during the examined one-year time period (2008 in Denmark and 2010 in Norway); nine units
accounted for 451 of the excluded MR episodes (> 25 per individual), leaving 1,938 episodes in
Denmark, and 989 in Norway for analysis.
Table 6 shows the results from the analyses.
29
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
Table 6. Effects of Potential Mechanical Restraint Preventive Factors on the Annual Number of Mechanical Restraint Episodes
Model 1
MR-preventive factors
Cognitive milieu therapy vs. no cognitive milieu therapy
Patient involvement vs. no patient involvement
Patient-centred care vs. no patient-centred care
Identification of the patient’s crisis triggers vs. no identification
Risk assessment vs. no risk assessment
Mandatory review vs. no mandatory review
Staff training (> 50% vs. less)
Positive staff attitudes vs. less positive
Patient-staff ratio (> 3 staff per patient vs. less)
Staff education (> 3 years vs. less)
Staff experience (> 5 years vs. less)
Debriefing, defusing vs. none
Positive patient responses to rules vs. negative responses
Activity-based nursing vs. no activity-based nursing
Acceptable work environment vs. poor work environment
No crowding vs. crowding
Substitute staff (< 50 vs. more)
Staff opposition to MR (many vs. some)
Alarm systems (many and well-trained responses vs. less well-trained responses)
Communication (all staff have communicative skills vs. less than all staff)
Well-maintained, clean and tidy surroundings (always vs. seldom)
Separation of acutely disturbed patients vs. no separation
Model 2
Model 3
exp(B)
95% CIs of
exp(B)
p
exp(B)
95% CIs of
exp(B)
p
exp(B)
95% CIs of
exp(B)
p
0.75
0.51
0.79
0.73
2.01
0.41
1.08
1.15
0.72
1.16
0.76
1.20
0.82
0.93
0.54
0.56
0.82
0.85
1.12
1.08
0.69
1.55
[0.26, 2.07]
[0.29, 0.88]
[0.30, 2.06]
[0.46, 1.15]
[0.84, 4.81]
[0.23, 0.73]
[0.69, 1.69]
[0.61, 2.16]
[0.42, 1.24]
[0.39, 3.41]
[0.47, 1.23]
[0.81, 1.70]
[0.46, 1.47]
[0.51, 1.70]
[0.33, 0.90]
[0.34, 0.92]
[0.51, 1.32]
[0.54, 1.34]
[0.42, 3.00]
[0.66, 1.75]
[0.41, 1.17]
[0.95, 2.52]
.57
.02
.62
.17
.12
.00
.74
.67
.24
.79
.27
.36
.50
.82
.02
.02
.42
.49
.82
.77
.17
.08
0.67
0.14
0.42
0.45
2.91
0.27
3.60
1.15
1.36
0.14
0.40
0.85
0.34
1.65
1.09
0.50
0.57
1.12
2.31
1.53
1.08
1.14
[0.37, 1.18]
[0.07, 0.30]
[0.17, 1.01]
[0.29, 0.72]
[1.28, 6.60]
[0.18, 0.39]
[2.49, 5.20]
[0.58, 2.26]
[0.83, 2.21]
[0.06, 0.32]
[0.24, 0.67]
[0.59, 1.22]
[0.19, 0.62]
[1.08, 2.51]
[0.76, 1.58]
[0.31, 0.80]
[0.33, 1.01]
[0.77, 1.62]
[1.15, 4.63]
[0.84, 2.81]
[0.71, 1.66]
[0.73, 1.78]
.17
.00
.05
.00
.01
.00
.00
.69
.22
.00
.00
.39
.00
.02
.64
.00
.05
.56
.02
.17
.72
.57
.
0.42
.
.
.
0.36
.
.
.
.
.
.
.
.
.
0.54
.
.
.
.
.
1.65
.
[0.25, 0.73]
.
.
.
[0.21, 0.63]
.
.
.
.
.
.
.
.
.
[0.36, 0.81]
.
.
.
.
.
[1.10, 2.49]
.
.00
.
.
.
.00
.
.
.
.
.
.
.
.
.
.00
.
.
.
.
.
.02
Note. MR = Mechanical restraint. The exp(B) parameters were estimated using a linear regression, and all three models were adjusted for the background variables: geography, unit size, bed occupancy, type of bed, reason for the MR,
forensic provision, ethnicity, and type of unit. Additionally, the nesting of units in departments was adjusted using GEE techniques. In Model 1, the MR-preventive factors were analysed alone. In Model 2, all MR-preventive factors were
analysed together. In Model 3, a forward-selection procedure included the most significant MR-preventive factors until the Corrected Quasi Likelihood under Independence Model Criterion (QICC) value began to rise. In all three models,
the outcome variable (i.e., the number of MR episodes) was log-transformed. Hence, the parameters should be interpreted multiplicatively (e.g., in Model 1, cognitive milieu therapy results in exp(B) = 0.75 times the average number of MR
incidents without cognitive milieu therapy (or 25% fewer MR episodes occur with cognitive milieu therapy compared with without therapy).  p < .01. The grey marking denotes the most important values.
30
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
Table 6 indicates that in Model 1, which evaluated the associations separately, only one MRpreventive factor was significantly associated with a low frequency of MR episodes: mandatory
review (exp[B] = .41, which is interpreted as a 1-.41 = 59% decrease in MR episodes).
In Model 2, in which the associations were evaluated jointly, seven MR-preventive factors were
significantly associated with a low frequency of MR episodes: patient involvement (exp[B] = .14),
staff education (exp[B] = .14); mandatory review (exp[B] = .27); positive patient responses to rules
(exp[B] = .34); staff experience (exp[B] = .40); identification of the patient’s crisis triggers (exp[B]
= .45); and crowding (exp[B] = .50). Staff training was the only MR-preventive factor that was
significantly associated with a high frequency of MR episodes (exp[B] = 3.60).
In Model 3, in which we attempted to strike a balance between residual confounding (Model 1) and
over-fitting (Model 2), three MR-preventive factors were significantly associated with a low
frequency of MR episodes: mandatory review (exp[B] = .36); patient involvement (exp[B] = .42);
and crowding (exp[B] = .54).
Pearson’s correlation matrix identified one highly correlated (Pearson’s r > .50) pair of MRpreventive factors: communication and positive staff attitudes (Pearson’s r = .77). Furthermore, the
following six pairs exhibited a medium correlation (Pearson’s r .30 ≤ .50): patient-centred care and
cognitive milieu therapy (Pearson’s r = .49); communication and staff opposition to MR (Pearson’s
r = .38); substitute staff and activity-based nursing (Pearson’s r = .36); communication and risk
assessment (Pearson’s r = .32); positive patient responses to rules and identification of the patient’s
crisis triggers (Pearson’s r = .31); and staff education and cognitive milieu therapy (Pearson’s r =
.31). All correlations were significant (p < .01).
7.4
Summary of Results, Study 4
Comparing the effect of non-medical mechanical restraint preventive factors between
psychiatric units in Denmark and Norway.
The data acquired from the cross-sectional questionnaire (the same as in Study 3) was analysed to
examine how presumed MR-preventive factors of non-medical origin may explain the differing
numbers of MR episodes between Denmark and Norway.
The responding and non-responding clinical nursing managers of the units were equally distributed
across the countries (overall response rate = 49%). Data from 43 and 47 units were included in
Denmark and Norway respectively. The reasons for non-response were indicated by the clinical
nurse managers as “change of clinical nurse manager” (n = 9), “lack of personal resources to
31
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
accomplish the task” (n = 7), sick leave (n = 5), inability to remember/identify the number of MR
episodes (n = 5), and lack of belief that this type of research was beneficial (n = 1). The remaining
63 nurse managers did not provide a reason.
The respondents reported 2,361 MR episodes in Denmark and 1,017 MR episodes in Norway
during the examined one-year period (2008 in Denmark and 2010 in Norway); nine units accounted
for 451 of the excluded MR episodes (> 25 per individual), leaving 1,938 episodes in Denmark, and
989 in Norway for analysis.
A difference in the number of MR episodes was observed between the countries in the model that
included the background variables (exp[B] = 1.92, p = .01); Denmark had 1.92 times as many (92%
more) MR episodes than Norway.
Table 7 shows the results of the analyses.
32
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
Table 7. Differences in the Effects of Potential Mechanical Restraint Preventive Factors on the Annual Number of Mechanical Restraint Episodes in Denmark and Norway
Denmark
MR-preventive factors
Cognitive milieu therapy vs. no cognitive milieu therapy
Patient involvement vs. no patient involvement
Patient-centred care vs. no patient-centred care
Identification of the patient’s crisis triggers vs. no identification
Risk assessment vs. almost none or no risk assessment
Mandatory review vs. no mandatory review
Staff training (> 50% vs. less)
Positive staff attitudes vs. less positive
Patient-staff ratio (> 3 staff per patient vs. less)
Staff education (> 3.5 years vs. less)
Staff experience (> 5 years vs. less)
Debriefing, defusing vs. none
Positive patient responses to rules vs. negative responses
Activity-based nursing vs. no activity-based nursing
Acceptable work environment vs. poor work environment
No crowding vs. crowding
Substitute staff (< 50 vs. more)
Staff opposition to MR (many vs. some)
Alarm systems (many and well-trained responses vs. less well-trained
responses)
Communication (all staff possess communicative skills vs. less than all staff)
Well-maintained, clean and tidy surroundings (always vs. seldom)
Separation of acutely disturbed patients vs. no separation
No % exp(B)
5
34
5
29
9
8
20
4
2
3
36
28
32
15
6
19
8
11
13
81
13
69
21
19
49
10
5
7
84
72
78
38
14
51
19
27
0.36
0.66
0.41
0.65
2.85
0.38
1.26
1.30
0.96
0.34
0.81
0.79
0.61
0.78
0.52
0.59
0.59
1.09
95% CIs
of exp(B)
[0.11, 1.16]
[0.26, 1.71]
[0.12, 1.38]
[0.38, 1.10]
[1.28, 6.36]
[0.15, 0.97]
[0.65, 2.46]
[0.56, 2.99]
[0.45, 2.06]
[0.17, 0.66]
[0.45, 1.44]
[0.46, 1.36]
[0.29, 1.29]
[0.34, 1.79]
[0.22, 1.25]
[0.31, 1.13]
[0.32, 1.10]
[0.47, 2.54]
Norway
p
.09
.40
.15
.11
.01
.04
.49
.54
.91
.00
.47
.40
.20
.56
.14
.11
.10
.84
3
86
10
93
37
15
48
28
53
93
98
65
85
54
40
59
73
39
7.46
0.60
5.01
0.75
1.39
0.53
0.88
1.28
0.62
0.76
0.56
2.04
1.92
0.69
0.55
0.55
0.54
0.70
95% CI
p
of exp(B)
[2.94, 18.89] .00
[0.27, 1.31] .20
[2.03, 12.36] .00
[0.26, 2.17] .59
[0.60, 3.26] .45
[0.21, 1.37] .19
[0.39, 2.01] .76
[0.53, 3.06] .59
[0.32, 1.19] .15
[0.28, 2.04] .59
[0.14, 2.19] .41
[1.07, 3.89] .03
[0.49, 7.44] .35
[0.25, 1.88] .47
[0.30, 1.03] .06
[0.27, 1.14] .11
[0.25, 1.18] .12
[0.30, 1.63] .41
No % exp(B)
1
37
4
40
17
7
21
13
25
43
44
24
34
22
17
20
33
17
SOI
χ2
Δ exp(B)
Interaction between
the MR-preventive
factor and the
country
Difference in the
prevalence of the
MR predictive factor
between countries
Difference in the
effect of country
p
p
%

.00
.80
.00
.67
.13
.97
.22
.75
.56
.05
.84
.02
.80
.53
.93
.22
.33
.65
.09
.53
.72
.01
.11
.60
.92
.03
.00
.00
.02
.52
.42
.14
.01
.53
.00
.25
6
-2
3
-10#
7
-1
0
3
-11#
-51#
-1
-3
-1
-6
-15#
6
-17#
-1
7 0.18
[0.03, 1.17] .07
5 11
3.72
[2.16, 6.41]
.00
.00
.50
4
8 20 1.56
23 55 0.89
21 50 1.05
[0.85, 2.85] .15
[0.42, 1.87] .75
[0.46, 2.40] .90
17 36
29 63
38 83
1.03
1.03
1.94
[0.51, 2.10]
[0.53, 2.04]
[0.92, 4.09]
.93
.92
.08
.43
.63
.28
.08
.43
.00
3
0
13#
3
Note. MR = Mechanical restraint. No = the number of units where the factor was present. % = the percentage of units where the factor was present. Exp(B) = the parameter estimate. The outcome variable (i.e., the number of MR episodes) was
log-transformed. Hence, the exp(B) should be interpreted multiplicatively (e.g., in Denmark, cognitive milieu therapy results in exp[B] = 0.36 times the average number of MR incidents without cognitive milieu therapy (or 64% fewer MR
episodes occur with cognitive milieu therapy compared without therapy). 95% CI of exp(B) = 95% Wald confidence interval for exp(B). p = p-value. SOI = second order interaction, p-value of a test for the interaction between the MRpreventive factor and the country, i.e., whether the effect of the MR-preventive factor differs between the countries. χ2 = p-value of a chi square test for the difference in the prevalence of the MR-preventive factor in the units between the
countries. Δ exp(B) = Differences in the effects of the country in models with and without the corresponding MR factor (confounding effect of the MR-preventive factor) expressed as a percentage; negative Δ exp(B) values should be
interpreted as a MR-preventive factor that minimises the difference between the countries. In the estimation of exp(B), SOI, and Δ exp(B), we used linear regression and adjusted for the following background variables: unit size, bed
occupancy, type of bed, reason for the MR, forensic provision, ethnicity, and type of unit. Additionally, the nesting of units in departments was adjusted using GEE techniques.  = p < .01. # = Δ exp(B) > +/- 10%. The grey marking denotes the
most important values.
33
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
Table 7 indicates the extent to which the MR-preventive factors explain the differences in MR
episodes between Denmark and Norway in several steps. The first column of results in Table 7, in
which the MR-preventive factors are evaluated in a similar fashion as in Table 6 (Model 1),
indicates that a single MR-preventive factor, staff education (exp[B] = 0.34, p = .00), was
significantly associated with a lower frequency of MR episodes in Denmark. In Norway, three MRpreventive factors were significantly associated with a higher frequency of MR episodes: cognitive
milieu therapy (exp[B] = 7.46, p = .00); patient-centred care (exp[B] = 5.01, p = .00); and alarm
systems (exp[B] = 3.72, p = .00). Notably, the confidence intervals for cognitive milieu therapy and
patient-centred care were large, reducing the precision of any estimates of an increase in the MR
episodes related to these factors.
Various effects noticeably differed between the countries. In the column marked SOI in Table 7, we
identified three incidences of an interaction between the MR-preventive factor and the countries:
cognitive milieu therapy (SOI, p = .00); patient-centred care (SOI, p = .01); and alarm systems
(SOI, p = .00). The presence of these factors exhibited a positive effect in Denmark (exp[B]: 0.36,
0.41, and 0.18) and a negative effect in Norway (exp[B]: 7.46, 5.01, and 3.72).
As shown in the column marked χ2 in Table 7, the prevalence was significantly different for six
MR-preventive factors between the two countries: the identification of a patient’s crisis triggers (χ2,
p = .01); patient-staff ratio (χ2, p = .00); staff education (χ2, p = .00); work environment (χ2, p =
.01); substitute staff (χ2, p = .00); and separation of acutely disturbed patients (χ2, p = .00). This
represents a criterion of the factors to represent a confounder for the association between country
and MR episodes.
In the last column of Table 7, six MR-preventive factors were identified, and confounding effects
were uncovered for the association between the country and the number of MR episodes, i.e., the
MR-preventive factor explained part of the difference in the number of MR episodes between
Denmark and Norway. A factor was identified as a confounder if the adjustments for this factor
changed the effects of the country by more than 10% (∆ exp[B] > 10%), and the identified factors
were as follows: identification of the patients’ crisis triggers (∆ exp[B] = -10%); patient-staff ratio
(∆ exp[B] = -11%); staff education (∆ exp[B] = -51%); work environment (∆ exp[B] = -15%);
substitute staff (∆ exp[B] = -17%); and separation of acutely disturbed patients (∆ exp[B] = 13%).
In both countries, the following MR-preventive factors were associated with lower numbers of MR
episodes: identification of patients’ crisis triggers (Denmark, exp[B] = 0.65; Norway, exp[B] =
0.75); the patient-staff ratio (Denmark, exp[B] = 0.96; Norway, exp[B] = 0.62); staff education
34
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
(Denmark, exp[B] = 0.34; Norway, exp[B] = 0.76); work environment (Denmark, exp[B] = 0.52;
Norway, exp[B] = 0.55); and substitute staff (Denmark, exp[B] = 0.59; Norway, exp[B] = 0.54). In
contrast, the separation of acutely disturbed patients was associated with increased MR episodes
(Denmark, exp[B] = 1.05; Norway, exp[B] = 1.94).
Corrigendum: Unfortunately, a minor error in the abstract of the paper were identified, the one MRpreventive factor not supported by earlier research was, “separation of acutely disturbed patients”
and not as written “the identification of the patient’s crisis triggers”.
8 Approval and Ethics
Literature reviews such as those in Studies 1 and 2, do not require approval from the scientific
ethical committee system (134). Questionnaire surveys such as those included in Studies 2, 3, and 4
do not require approval from the scientific ethical committee systems of the included European
countries if, respondents are able to provide informed consent or if sensitive information is not
collected. The Danish Data Protection Agency (Journal number: 2007-2058-0015, PSV-2009-2013)
approved the studies and we received permission from the Danish Health and Medicines Authorities
and the Danish Psychiatric Central Research Register to use the register data on the frequency of
MR in Denmark (31) (Journal number: 7-505-29-1246/1). The studies followed the Ethical
Guidelines for Nursing Research in the Nordic Countries (135) and the White Paper Regarding a
Draft Recommendation on Legal Protection of Persons Suffering From Mental Disorder Especially
Those Placed as Involuntary Patients (136).
9 Discussion
9.1
Discussion of Individual Studies
Study 1: Cognitive milieu therapy combined with patient involvement was highest ranked MRpreventive factor. To the best of our knowledge, this result has not been identified in prior reviews.
One possible explanation for this could be that the cognitive milieu therapy paper (72) was not
published in English; the abstract of this study only described a significant effect and did not quote
an exact figure such as a staggering 87% reduction. Later research by Chang (137) supported this
finding; this before-and-after study showed a reduction in seclusion and restraint episodes following
the implementation of a cognitive therapy training program. Cognitive milieu therapy is an active,
structured, problem-orientated, psycho-educational, and dynamic type of care. Cognitive care
35
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
models in this environment give the patient the opportunity to implement new alternatives to
inappropriate reaction patterns while also developing new skills (138). One of the core issues in
cognitive milieu therapy is a schema-focused dialog between the patient and the nursing staff during
situations just before potential MR use. In this moment, the patient has the opportunity to try new
actions. This type of patient involvement has also been addressed elsewhere (73) as having a
positive influence on the incidence of MR. A later paper by Soininen (139) agreed, concluding that
patients´ opinions required greater attention in treatment decisions. Several studies have examined
the effect of implementing the “six core strategies” (103;140-147), one of which touts patient
involvement. The reason for the present high recommendation grade is the combination of cognitive
milieu therapy and patient involvement, because, cognitive milieu therapy had a high effect and
patient involvement had high evidence. Synthesising these together adding evidence to cognitive
milieu therapy is possible the correct deduction, because patient involvement is part of the care
model, all though patient involvement could as well be a phenomenon on its own.
The second highest ranked MR-preventive factor was not one particular intervention but rather
programs including several interventions such as patient participation, patient education, staff
education, programmatic changes, high-level administrative endorsement, cultural changes, and
data analysis. Several papers have described different programs (45;46;74-76), indicating an
average decrease in the number of MR episodes of 76%. The evidence mostly comprises “beforeand-after” papers; because some of these papers are well founded, the recommendation grade is the
same as in the first MR-preventive factor. Later research describing combined interventions with a
higher evidence grade (145) could move this MR-preventive factor up in the hierarchy.
The third highest ranked MR-preventive factor was the implementation of patient-centred care
combined with patient involvement. Here, implementation of the Tidal Model reduced the number
of mechanical restraints by 68% (77;78). The Tidal Model is a philosophical approach to mental
health discovery that focuses on helping people who have experienced a metaphorical “breakdown”
to recover their lives as fully as possible by reclaiming their personal stories of distress and
difficulty (148). One of the core elements in the Tidal Model is patient empowerment.
Empowerment is only possible if the patients are involved in their own care. Elsewhere, patient
involvement has also been found (73) to positively influence the occurrence of MR. Thus, the
recommendation grade is the same as in the second MR-preventive factor. As in the first MRpreventive factor, the reason for the high recommendation grade was the combination of patientcentred care and patient involvement, where patient-centred care had a high effect and patient
involvement had high evidence. Synthesising these together adding evidence to the Tidal Model is
36
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
possible the correct deduction, because patient involvement is part of the care model, all though
patient involvement could as well be a phenomenon on its own.
The MR-preventive factor with the highest recommendation grade was no. 5, the introduction of
validated risk assessment systems. This has later been supported by one additional cluster RCT by
van de Sande (149), investigating implementation of crisis monitoring instruments (Kennedy Axis
V and Brøset Violence Checklist [BVC]), the result indicated an insignificant difference between
the experimental wards and the control wards of -15% in the risk ratio of seclusion incidents (15%
lower risk after the implementation). The difference in the duration of seclusion was significant,
with a risk ratio = -45%. These findings added further evidence to this MR-preventive factor,
although, it did not change its place in the hierarchy, based on the risk of moderately occurring bias
in the study (not blinded and small clusters) and the continuously low effect.
When introducing MR-preventive initiatives, only two of the 59 papers described adverse effects
(negative consequences), concluding that adverse effects very seldom arises. Never the less,
following measures of important adverse effects should always be addressed, when introducing new
MR-preventive initiatives.
The evidence supporting the different MR-preventive factors has improved since April 2009 (when
study inclusion in the systematic review ended). Some of these factors were included in the former
discussion of the individual MR-preventive factors; these factors will continue to improve over the
next few years. A superficial update in December 2014 revealed 64 new papers. Thus, few MRpreventive factors are closing in on the highest recommendation grade, although no MR-preventive
factor has reached the highest recommendation grade.
Study 2: This study was not planned to be as an analytic study but took on a more descriptive
nature, enabling statistical analyses of the differences among the European countries. For the
purpose of this thesis, the data regarding Denmark and Norway are discussed.
The number of psychiatric beds was almost twice as high per 100,000 inhabitants in Norway (61,
119) as in Denmark. This trend could be due to the actual numbers or to way the numbers were
extracted or recorded by the WHO (55). Investigating later data from the countries central statistical
population registers and patient registers, the numbers of mental health hospital beds per 100,000
inhabitants were Denmark, 23.96 and Norway, 22.81, pertaining to the years of 2008 and 2010 (the
years of the later questionnaire survey). So the data recorded by the WHO, did not seem accurate.
The number of forced admissions was almost twice as high per 100,000 inhabitants; this finding
could indicate that patients in Norway were admitted earlier, before they became as aggressive or
37
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
suicidal as patients in Denmark. Alternatively, Denmark has many more forensic psychiatric
patients (in 2010, 2,638 forensic psychiatric patients (150)) compared with Norway’s maximum of
approximately 500 (the exact number is unknown); although they were unwillingly placed in a
psychiatric unit, these patients were not included in the numbers of forced admission .
In Norway, there are no specialised psychiatric forensic beds. Regional security departments admit
the most aggressive or agitated patients. In Denmark, many forensic patients are placed in ordinary
beds, and only the most severe patients are placed in the special forensic units.
Denmark had fewer psychiatrists than Norway per 100,000 inhabitants, which could indicate that
treatment in Norway is more available and of higher quality.
In 2007, Denmark used more MR and physical restraint/holding than Norway. This finding is not
easily explained due to the many similarities in legislation (64;65) and treatment culture (10)
between the two countries. Norway used more seclusion/isolation than Denmark, but no numbers
from the Danish high security department were available to further qualify this difference. Overall,
the numbers are small and do not sufficiently explain the differences in the MR and physical
restraint/holding figures. Regarding the validity of these figures, in both countries registration of
coercive measures are compulsory by law. The figures from Norway were scrutinised by Bremmes
(67), who collected complete figures from all institutions using coercive measures. Knutzen (151)
have validated 98 randomly selected reasons for restraint, finding kappa values between 0.71 and
0.94 (substantial agreement to almost perfect agreement), the scrutinised protocols were obtained
from three psychiatric wards. Although, the Danish figures have not been scientifically validated,
the nursing heads of the units answered affirmatively when asked whether all coercive measures
had been reported. Furthermore, upon comparing the individual numbers of written records from
seven randomly selected units with the national register, the highest difference found was less than
3%. Therefore, the differences between the figures are not likely due to imprecise registration
practices. A possible explanation could be different medication practises; this does not apply for
forced medication/short period, which showed the same tendencies as MR and physical
restraint/holding (in 2009, 107 and 39 episodes per 100,000 inhabitants were recorded in Denmark
and Norway, respectively (47;152)), but perhaps for forced medication/long period. In 2013, the
number of forced medications was 15.7 and 24.0 per 100,000 inhabitants in Denmark (26) and
Norway (153), respectively; some of the differences in MR and physical restraint/holding numbers
could perhaps be explained by earlier medication use and the inclusion of more patients in a longer
medication period; this does not likely explain much of the difference because Denmark more
38
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
frequently uses forced medication/short period. The last difference regarding medication use could
involve differences in the overall amount or the number of doses of medicine, which are indicative
of different treatment cultures. The only study found that described this condition was
“Comparisons of psychotropic drug prescribing patterns in acute psychiatric wards across Europe”
(154), which did not describe the actual relationship between coercion and medication but rather
described medication practises in general. This study did not show country differences but did show
department differences. Thus, the lower frequency of MR and physical restraint/holding in Norway
likely indicates that other factors are “responsible” for the differences.
The degrees of perceived intrusion of the coercive measures were perceived differently in the two
countries. In Denmark, ambulatory MR, MR, and seclusion/isolation are perceived to be the most
intrusive, whereas in Norway, forced medications are perceived as the most intrusive. In particular,
the difference regarding forced medication/short period is described within the Norwegian
legislation in the following order: MR, isolation, forced medication (isolated episode), and finally,
physical restraint (lasting for a short period of time) (65). This order is the same as in the Danish
legislation, except for isolation (which is only used in a special high security department) (64).
Normally, the most intrusive intervention would be listed first; thus, a misunderstanding on behalf
of the Norwegian representative of the concepts “short period” vs. “isolated episode” may have
occurred, thereby increasing the similarities between the countries.
Study 3: Mandatory review was significant in all three models; correspondingly, no significant
inter-correlations with the other factors were identified. Thus, no other factors greatly confounded
the association between mandatory review and the number of MR episodes. Mandatory review
should be interpreted as follows: the units in which the staff audited, reviewed or conducted a
similar systematic follow-up period after each MR episode (to analyse and learn from the episodes)
experienced an average of .36 times as many (or 64% fewer) MR episodes compared with units in
which a review was conducted only after some episodes or the unit did not conduct a review
process. This finding is in line with previous research, which also reported that conducting
mandatory reviews of MR episodes was associated with a lower number of MR episodes
(87;88;155-157). Previous research has suggested that an optimal process should review all MR
episodes within a few days and the review board should comprise an interdisciplinary team,
including a nurse specialist, a physician, a psychologist, and the clinical department heads with the
supervisory authority to change nursing and treatment practices. Additionally, the review process
should require a protocol that includes a description of the episode, the environmental conditions
that might have provoked the problem behaviour, possible “crisis triggers,” any unique calming
39
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
techniques identified, patient involvement, medications, and any behavioural treatments and milieu
therapies, among other items. Later research also supports this, several studies examining the effect
of implementing “the six core strategies” (103;140-147), wherein one of the strategies deals with
mandatory review (debriefings), a RCT found a difference between the control wards and the
intervention wards of 62%, other studies found an even higher effect. Overall, present research of
reasonable quality supports mandatory review.
Patient involvement was significant in both Models 2 and 3; the fact that patient involvement was
not significant in Model 1 could be explained by the correlations with other factors (albeit not
strongly or significantly), e.g., staff training and well-maintained, clean and tidy surroundings. The
elements of patient involvement are potentially included in some staff training, and patients who are
more involved in their own care may have a greater sense of responsibility towards their
surroundings. Thus, the non-significant findings presented in the correlation matrix with regard to
patient involvement do not precisely explain which factors influence the association between patient
involvement and the number of MR episodes. Patient involvement should be interpreted as follows:
units in which the patients participated in ward rounds/conferences, influenced the rules applied to
the unit, or influenced what was written in the nurse’s journal experienced an average of .42 times
as many (or 58% fewer) MR episodes compared with the units in which no such participation
occured. Previous research demonstrated that patient involvement might reduce MR episodes
(73;141), and more resent research also supports this idea. Soininen (139) concluded that patients´
opinions require more attention during treatment decisions. In several studies examining the effect
of implementing the “six core strategies” (103;140-147), one of the strategies represent an approach
to address patient involvement, one RCT found a difference between the control wards and the
intervention wards of 62% Subsequent studies found an even higher effect. In this study, patient
involvement was measured using three items (whether the patients participated in ward
rounds/conferences; whether they influenced the rules; and whether they affected what was written
in the nurses’ journals). Patient involvement is a very complex phenomenon and, includes the
concept that the patient is the expert on his or her life and that the staff members are experts with
regard to the patient’s care or treatment. Accordingly actions are negotiated via dialogue. However,
units with a recovery-orientated or empowering approach, that integrate patient involvement with
the delivery of care and treatment schould include one of the aforementioned items (whether the
patients participated in ward rounds/conferences; whether they influenced the rules; and whether
they affected what was written in the nurses’ journals). Overall, patient involvement has been
strongly supported as a MR-preventive factor by other research.
40
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
Crowding was significant in both Models 2 and 3; one minor but significant inter-correlation
between crowding and the staff-patient ratio was identified (Pearson’s r = .24, p < .05). This intercorrelation is logical as more staff creates a perception of more crowding. Crowding should be
interpreted as follows: units in which two of three conditions were present experienced an average
of .54 times (or 46% fewer) MR episodes compared with the units where only one or none of the
conditions was present: only one bed in a patient’s room, more than 25 m2 of all-day-accessible
space per patient, and the perception of no crowding. Previous research demonstrated that no
crowding might influence the number of MR episodes (81;119;158;159), but none of the four
studies supports a causal relationship with the number of MR episodes.
One of the MR preventive factors identified in the systematic literature review, namely risk
assessment, has been supported by some of the strongest evidence, including two cluster RCTs. One
study showed a reduction of 27% in coercive measures (83), and the other showed an insignificant
difference of -15% between experimental and control wards in the risk ratio of seclusion incidents
(149). We have not found a significant relationship between risk assessment and MR reduction in
this study due to the combination of risk assessments for self-destructive/suicidal behaviours and
aggressive/violent behaviours. The difference in the risk assessments of self- destructive behaviours
is most likely impossible to measure because both Denmark and Norway have focused on this
factor over the past several years; thus, almost all institutions have implemented this assessment
system. The independent assessment of aggressive/violent behaviour has also become more
common. Fifty-five per cent of the patients in the units were systematically assessed for the risk of
developing aggressive or violent behaviours; however, this assessment system appears to have been
initially introduced in units with high numbers of MR episodes. Another explanation could be that
the effect of implementing risk assessment tools was not large enough to be identified in this study.
Study 4: Three potential MR-preventive factors displayed very different effects in the two
countries; these factors were demonstrated by significant interactions between the MR-preventive
factor (cognitive milieu therapy, patient-centred care, and alarm systems) and the country. Each
factor exhibited a positive effect in Denmark and a negative effect in Norway, but the prevalence
did not differ between the countries. Because of the different effects, the degree of confounding (∆
exp[B]) is impossible to interpret. Although this topic is potentially interesting, we cannot provide
clear reasons as to why these factors exhibited different effects in the two countries. Further
research is required to explore the different effects of these three MR-preventive factors.
41
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
Six MR-preventive factors exhibited a significant difference between the countries with regard to
the frequency of MR episodes (∆ exp[B]).
First, staff education: Differences were observed in units in which the staff received basic training
for at least three and a half years vs. units in which the staff had less than three and a half years of
training. This factor explains a large portion (∆ exp[B] = -51%) of the difference in MR episodes
between the countries. Staff education has been supported by earlier research. Jannsen (108)
reported that seclusion was used more often in units with less-educated staff in the long-term wards.
Gim (106) found a significant difference between psychiatric-trained and non-psychiatric-trained
staff in identifying and managing the precipitants of violence. In a large 20-year analysis of 1,565
mental health workers, Flannery (160) found that staff who were victims of patients aggression
were less formally educated and less trained. None of the studies were RCTs, but well designed
otherwise, it is reasonable to deduce, that earlier research supports the role of staff education, in the
difference in MR use between the two countries. Higher basic education among the staff probably
leaves them with higher analytic, and action competences, even in situations of crisis, thereby
reducing the number of MR episodes.
Second, substitute staff: Differences were observed in units in which substitute staff was used fewer
than 50 times (8-hour shifts) over the year vs. units in which these employees were used greater
than or equal to 50 times. The factor explains a large proportion (∆ exp[B] = -17%) of the
difference in MR episodes between the countries. The effects of substitute staff were supported by
earlier research. Bonner (20) found that both patients and staff discriminated between permanent
and regular staff. Bowers (120) reported that adverse incidents were more likely to occur in weeks
during which the regular staff was absent. In another study, Bowers (161) noted that increased
levels of aggression were associated with an increased use of bank and agency staff. None of the
studies were RCTs, but all indicated similar results supporting less use of substitute staff. The
substitute staff may lack knowledge of the structures, processes, and patients in the units thereby
creating insecurity and disturbances among the most vulnerable patients in the unit. This could be a
stressing factor for the patients leading to more aggressive or self-destructive behaviours and hence
more MR episodes.
Third, work environment: Differences were found in units in which a workplace environment
assessment was conducted no or only insignificant physical or mental work-environment problems
existed, and the overall work environment was evaluated as acceptable vs. units in which the
workplace environment was not assessed, more work-environment problems existed, and the
42
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
overall work environment was evaluated as poor. This factor explains a large proportion (∆ exp[B]
= -15%) of the differences in MR episodes between the countries. Assessing the work environment
is somewhat complex due to the mix of leadership, degree of order, organisation, staffing, training,
and crowding, among other factors. De Benedictis (162) reported that several organisational factors,
e.g., team climate, staff perception of aggression and interaction of team-members, were associated
with an increased use of seclusion and restraint. Hanrahan (163), observed a relationship between
psychiatric nurses’ work environments and inpatients’ environments. Van der Schaff (158),
reported a number of building design features that affect seclusion and restraint. Virtanen (159),
indicated that patient overcrowding was associated with violent assaults towards employees.
Huckshorn (143), found that leaders played a critical role in reducing seclusion and restraint.
Camarino (164), found a significant association between work-related factors and certain types of
violence. Some of the other examined factors such as staff training and the staff/patient ratio also
contribute to the overall work environment. Overall, research supporting the association between
MR use and the work environment covers many aspects of a healthy work environment supporting
the role of the work environment in accounting for the difference in MR use between the two
countries. Regardless of which piece creates a positive work environment, the wellbeing of the staff
most certainly affects the wellbeing of the patients. Accordingly, if staff members experience a
more positive work environment, then the patient likely also experiences a more positive
environment.
Fourth, patient-staff ratio: Differences were observed in units in which the staff-to-patient ratio was
higher than or equal to three-to-one on average vs. those units in which this ratio was lower than
three-to-one. In Denmark, the effect was small, possibly due to the small number of units with an
average staff-to-patient ratio higher than three-to-one. This factor explains a large proportion (∆
exp[B] = -11%) of the difference in MR episodes between the countries. The effects of the staff-topatient ratio were partially supported by earlier research. Smith (103) found a 66% decrease in
restraint episodes. However, because several factors contributed to the observed effect, the
proportion of the MR reduction that is attributable to the 50% increase in staffing remains unclear.
Jannsen (108) found that seclusion was more commonly used if the number of patients per staff was
greater, in this case in long-term wards. Donat (165) reported a significant association between
increased staffing levels and decreased MR and seclusion numbers. However, Owen (117) noted
that the relative risk of violence increased with more nursing staff. Additionally, Bowers (161)
reported that increased levels of aggressive incidents were associated with increased staffing.
Nonetheless, these studies with opposite outcomes did not precisely target MR or seclusion and
43
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
instead focused on violence and aggression; thus their results could have been influenced by staff
employment policies, which state that staffing levels are to be increased in units with more
aggressive incidents. Our study most likely eliminated this problem by introducing “type of unit”
and “type of bed” as confounders. Overall, earlier research specifically dealing with the same
conditions supports the finding that the staff-to-patient ratio plays a role in explaining the difference
in MR use between the two countries. The mechanisms involved in higher staffing levels suggest
that, in such scenarios, the staff may be more able to observe, interact, and cooperate with the
patients, likely reducing the number of stressed staff members and thereby calming the
environment. The presence of more personal resources for positive reinforcement, support, and
communication, would hopefully create a more empowering and recovery-orientated environment
for patients.
Fifth, identification of a patient’s crisis triggers: Differences were found in units in which the initial
nurse evaluation of at-risk patients always contained a written evaluation of aggressive, selfmutilating, or suicidal behaviours (e.g., crisis triggers, unique calming techniques, and coping
strategies) vs. units in which the initial evaluation only occasionally or never contained a written
evaluation. This factor explains a large proportion (∆ exp[B] = -10%) of the difference in MR
episodes between the countries. The identification of a patient’s crisis triggers has been supported
by earlier research. In a well-designed before-and-after study, Jonikas (79) observed a significant
decrease (between 49% and 99%) in physical restraint episodes after patients were interviewed to
determine their crisis triggers and personal crisis management strategies. In a well-designed cluster
RCT, Putkonen (145) reported the same tendency, in which the difference between the intervention
and control wards was a 62% reduction in seclusion and restraint time after implementing “six core
strategies” to prevent seclusion and restraint. In both studies, the effect was attributed to variables
other than the patients’ crisis triggers. In a one-way case-crossover-designed study, Fluttert (166)
reported that implementing the Early Recognition Method (ERM) decreased the number of
seclusions by 54%. The ERM is a technique used by patients and staff to systematically work with
the patients’ triggers (early warning signs), crisis intervention, and coping strategies; this is the
same identification procedure that we asked the clinical nurse managers about in the questionnaire.
Overall, earlier research supports the finding that, identification of a patient’s crisis triggers, is a key
part of explaining the difference in MR use between the two countries. The mechanism underlying
this process is likely that patients and staff recognise earlier signs of a forthcoming crisis and act
together to counteract escalation of the crisis, thereby reducing the risk of a MR episode.
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Sixth, the separation of acutely disturbed patients: This single factor had opposing results in that
units that were able to separate acutely disturbed patients from other patients had more MR
episodes vs. units that were unable to separate patients. The factor explains a large proportion (∆
exp[B] = 13%) of the difference in MR episodes between the countries. This negative association
has not been supported by earlier research; in fact, the opposite results have been indicated. In a
qualitative content analysis study, Meehan (81) noted that the separation of acutely disturbed
patients would reduce the number of aggressive incidents. Because this result is not supported by
earlier research, more research is needed to explore the mechanisms involved in placing one or a
few patients in a separate and isolated part of the unit.
9.2
Design Issues
The initial systematic review was conducted to identify evident and effective MR-preventive
factors. We quickly realised that no meta-analyses or meta-syntheses were available. Insufficient
high-quality studies covering individual MR-preventive factors were also not found; thus,
performing our own was not possible, although this approach would have been optimal. Through
such an approach, Studies 3 and 4 would have included powerful hypothesis testing for the effects
of the MR-preventive factors in practice. Instead a combined systematic review was developed to
identify as many evident and effective MR-preventive factors as possible. The combination of
quantitative and qualitative research results might be controversial, but this is becoming more
common in highly complex research areas involving human interaction (167). Often the qualitative
research is only “recognised” as the lowest recommendation grade, in line with the opinions of
respected authorities or reports of expert committees, and not as “real” research. To establish the
more evident power of qualitative research, Kearney’s (50) qualitative hierarchy was introduced in
the model. Still, in the effect and recommendation grade matrix, the effect side of the matrix is
“flawed” due to the basic qualitative research methodology, which does not provide an effect as part
of the results or findings. For example, if the combined research does not include quantitative
research, it is only provided with an effect of five (the lowest effect level). Regardless, this review
does provide more evident “power” for the qualitative research and thereby the combined evidence
is greater than of earlier reviews regarding complex areas involving human interaction (MRprevention). Unfortunately, none of the identified MR-preventive factors reached the top end of the
evidence hierarchy (here the effect size of the matrix was not very important because this would
have been the objective of later investigation) and were unable to provide Studies 3 and 4 with the
possibility of powerful hypotheses testing for the effects of the MR-preventives factors in practice.
Instead, almost all of the results from the systematic review were investigated in the later studies.
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Regarding the comparative investigation of the use of coercive measures in Europe, this was
designed as a combination of a literature review and a questionnaire survey. This design was chosen
because it allowed for the investigation of practices in a large population in an inexpensive and
timesaving maner. A more thorough and ”scientific” design would have be required to examine all
parties involved in coercive procedures (e.g., health authorities, psychiatrists, nurses, and patients)
using large-scale questionnaire survey or personal interviews regarding the procedures, practices,
and the actual use of these measures. This approach would have produced data of a more evident
character for analytic investigation. However, this approach would have been very comprehensive,
difficult, and expensive to undertake, which was not the task at hand.
The two last studies were based on a questionnaire survey, designed to investigate the relationship
between the number of MR episodes and the degree to which the MR-preventive factors were
implemented in the “closed” units, at a single time point (cross-sectional). This design was chosen
because it made it possible to investigate large populations (Danish and Norwegian “closed”
psychiatry) and complex phenomena (many MR-preventive factors and confounders) in a
reasonable, inexpensive and not very time-consuming maner. Theoretically, the best design would
have been to conduct RCTs of all individual MR-preventive factors and to compare the results of
these trials. Apart from the excessive use of resources and the lack of psychiatric units necessary to
obtain sufficient power in the analyses, such a practice would be impossible because most patients
who experience MR are under involuntary/forced admission and are therefore not allowed to
participate in trials by law. Another approach would have been to allocate the MR-preventive
factors to the units in an efficient experimental design, removing the need for many RCTs.
However, given the number of MR-preventive factors requiring envestigation, this approach would
still require too many units. Furthermore, many units have previously implemented certain MRpreventive factors. A third approach could be to use a case-control design asking outpatients how
and to what extent they had experienced MR-preventive factors (using those who had experienced
MR as cases, and those who had not experienced MR as controls). In this scheme, investigating
many MR-preventive factors would not be possible because the outpatients would not possess the
required information, e.g., patient-staff ratio, staff experience, staff education, and risk assessment.
The last approach that may have constituted a stronger design would have been to repeat the data
collection over time and to examine the changes in the extent to which MR-preventive factors were
implemented and in the number of MR episodes. However, this design was not chosen due to the
limited study period and problems with organisational changes, thus, some units experience changes
in functions and leaders over a short period of time. The changes in organisational factors would
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have confounded the effects, thus minimising the validity of the study outcome. Ultimately, the
chosen design was preferred to investigate multiple MR-preventive factors and confounders in a
population of this size.
The analytic design of Study 3 was used to identify potential associations between the number of
MR episodes and the MR-preventive factors. In Study 4 similar analysis was applied to determine
the degree which the MR-preventive factors could explain the different numbers of MR episodes
between Denmark and Norway. For the main analyses linear regression was chosen because it is a
common and well-known statistical model that yiels easily interpretable results, although,
categorising the MR-preventive factors and logarithmically transforming the outcome variable (the
number of MR episodes) were nessesary. Because the outcome was a count, Generalised Linear
Models (GLMs) e.g. Poison regression could have been optimal, however, the logarithmically
transformed outcome variable in a linear regression model, provided a better fit for the statistical
model for the dataset (GEE, Quasi Likelihood under Independence Model Criterion [QIC]: 83,417),
than Poisson regression (GLM, QIC: 215,816). The resulting model investigated the outcome
variable and all MR-preventive factors and covariates/confounders (one nested) in a large
population. Using the GEE technique for nesting, we were able to include dichotomised,
categorised, and linear covariates in the models.
9.3
Cause and Effect
A causal association is one in which a change in the exposure frequency results in a corresponding
change in the outcome frequency. Making judgments about causality involves a chain of logic: first,
whether the statistical association is valid (chance); next, the strength of the association and to its
biological credibility; and finally, the generalisability and consistency of the results with those of
other investigations. Assessing the statistical validity of the association involves determining the
likelihood that alternative explanations such as chance, bias, or confounding could account for the
findings (168).
9.3.1
Chance
Chance refers to whether the included participants represent the whole population (168).
In Study 1, this objective could be translated as whether all of the papers dealing with MRprevention were obtained in the search strategy; the answer is likely not. However, no other
literature reviews at the time had coved other MR-preventive issues, and none included other
references. As a result, a very large portion of the available MR-preventive literature was found and
investigated.
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In Study 2, all EPSO members did answer the questionnaire, but very few UEMS members
answered the questionnaire, thus ascertaining any possible differences between the current
legislation and how tits transformed into practice, was impossible. Although we believe that the
UEMS members represent the whole population of their country, regarding national legislation, we
did not consider questions regarding general perceptions of the intrusiveness of coercive
interventions, which could be coloured by an individual’s personal beliefs, to represent the whole
population. However, most countries have addressed this question within their legislation (using the
measure of less intrusiveness) to disconnect this decision from personal beliefs. Overall, the
answers represent the whole population regarding the legislation, if not necessarily the actual
practise.
In Studies 3 and 4, a response rate of 49% was obtained. Therefore, we can only apply our results to
the entire population with some measures of certainty due to the risk of systematic differences
between responders and non-responders. Regarding the risk of systematic flaws or differences, we
reviewed the non-responders’ reasons for not responding. Most reasons appeared to be unrelated to
the questions under investigation. If a failure to respond was caused by a failure to implement
preventive factors or connected with high numbers of MR episodes, then our results would be
strengthen our findings would be underestimated. A proper drop-out analysis has not been
conducted; consequently it is unknown whether the high drop-out rate resulted in systematic flaws.
9.3.2
Bias
Bias is an alternative explanation for an observed relationship of an exposure with the outcome in
which some aspect of the design or execution of a study introduces a systematic error into the
results (168).
Selection bias is normally described as using non-comparable criteria to enrol participants in an
investigation (168). In Study 1, this could be translated, to the use of different criteria for sifting,
grading, and synthesising the evidence. Only one person was involved in the initial review process,
up to the drafting of evidence statements. Arguably, two or more persons reading all of the material
followed by consensus evaluations, would produce more reliable results; however, this could have
introduced inter-rater differences. To reduce bias, all of the evidence was gathered and strictly rated
according to set schemes in exactly the same manner. In Study 2 the enrolment criteria for the
questionnaire survey were the same for all responders; we presume that the staff who responded
was knowledgeable in the area of metal health legislation. Regarding the literature review, this
process was conducted by several people to screen for background variables and numbers on
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coercion mostly due to the limited data available at the time. In Studies 3 and 4, a type of selection
bias sometimes called non-respondent bias might have emerged between the respondent and the
non-respondent groups. The non-responders’ reasons for failure to reply were reviewed, and no
systematic differences were observed between the responders and non-responders, Still, a proper
dropout analysis was not conducted. Reviewing the Danish National Register on coercion, we found
that 49% of the responding units were “responsible” for 52% of the MR episodes in the same
population, suggesting minimal differences in MR episodes between responders and nonresponders.
Recall bias may arise because individuals with particular exposure or adverse health outcome are
likely to remember their experiences differently from those who are not similarly affected (168). In
Studies 1 and 2, recall bias was not an issue. In Studies 3 and 4, recall bias could have occurred,
especially for the Danish data; the clinical nurse manager had to recall all MR-preventive factors as
well as the conditions and numbers of MR episodes from two years prior. Although, an earlier study
determined that nurse recall is reliable for 4 weeks (169), the clinical nurse managers in these
studies were able to support their memories by referring to charts and protocols to answer many of
the questions. The outcome variable (i.e., the number of MR episodes) was validated or reexamined revealing that no significant recall bias existed with regard to the outcome variable.
Additionally, recall bias could have affected the results if the MR-preventive factors had only been
implemented for a portion of the year. Regardless, possible recall bias would likely only increase
the effect. Still, we must consider the possibility of recall bias with regard to certain variables.
Measurement-/insensitive measures of bias arise if the items in a questionnaire survey are not
sensitive enough to detect potential important factors (170). In Study 2, the questionnaire survey
only addressed interpretative legislative areas, not revealing any non-detection of important matters.
In Studies 3 and 4, such significant non-detection could be of concern. However, the findings were
probably quite conservative, underestimating the actual effect, because the questionnaire only
roughly covered the MR-preventive factors with questions that could measure all aspects of such a
MR-preventive factor. A MR-preventive factor such as the patient-staff ratio is simple and straightforward, but a more complex MR-preventive factor such as cognitive milieu therapy, could lack the
sensitivity to identify the most important MR-preventive responses due to the many relevant aspects
such as a clear objective, a described philosophy, management support and knowledge, the
economy, qualified supervisors, cultural changes, and patient education and involvement, among
others. Still, complex MR-preventive factors may have a greater impact on the reduction of MR
episodes than those found in Studies 3 and 4.
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Expectation bias occurs when participants err in measuring data towards the expected outcome
(170). In Studies 3 and 4, the number of MRs was an important outcome, and most of the data
regarding outcome were taken from existing electronic or paper charts with no obvious
manipulation. Whether the clinical nurse managers err toward the expected outcome when
measuring certain preventive factors is unknown. However, clinical nurse managers were urged to
describe the conditions of the unit in a neutral manner.
Analysis or transfer bias occurs upon transferring the data into organised structures for analysis
(170). In Studies 3 and 4, this problem was likely avoided in the design phase, during which
definitions, hypotheses, and analyses were prepared and scrutinised.
Cognitive dissonance bias occurs if the investigator is convinced that his or her beliefs about the
findings are valid, regardless of findings to the contrary (170). Because Studies 3 and 4, reexamines the preventive factors that others have previously described, the risk of cognitive
dissonance bias is minimal.
Biases in questionnaires, is an important issue in this thesis. A couple has been addressed earlier,
but most of the many types of bias must be eliminated in the construct-phase, as follows: in
designing questions, in designing the questionnaire, and in administration of the questionnaire. Choi
(171) describes in all 48 common types of bias in questionnaires, nearly all eliminated by strictly
following the guide by Olsen (63) in Study 2, and following QAS-99 by Willis (68), concurrent
probing by Watt (70), and cognitive interviews by Willis (69) in Studies 3 and 4.
9.3.3
Confounding
Confounding can be thought of as a mixing of the effect of the exposure on the outcome with a third
factor. This third factor must be associated with the exposure and the outcome, independently of
that exposure (168). In Studies 1 and 2, confounding was important in the assessment of the
individual papers included in the literature reviews, but was otherwise not an issue because the
studies were not analytic. In Studies 3 and 4 confounding was a very important issue. In Study 3,
certain confounding covariates e.g. patient flow, diagnostic distribution, different population bases
of the units and age of the patients who experienced MR, might be missing from the analyses.
However, the previously described covariates did not act as confounders in Denmark because the
geographic regions and types of the units functioned as proxy covariates. Geographic regions
eliminated the confounding effect of the different population base of the units, and the type of unit
eliminated the confounding effect of the diagnostic distribution, patient flow, and age of the
patients. These effects were determined by analysing data from the Danish National Register on
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Coercion and the Danish Psychiatric Research Register. However, these data could not be accessed
in the Norwegian sample; therefore, whether these conclusions apply to the entire dataset remains
unknown, although it is reasonable to deduce that they do. In Study 4, the same considerations
regarding confounding covariates were made, except that, patients who experienced MR were
thought to be more aggressive or self-mutilating in one of the countries, which represented a
confounder. However, an earlier study that assessed aggressive behavior (172) did not report large
differences between Denmark and Norway. Additionally, some of the covariates (number of
forensic patients, type of bed, and the reason for MR) could eliminate portions of the difference.
Thus, the potential differences in aggressive or self-mutilating patients did not likely influence the
results. Overall, the most important covariates either were included or covered the effects of others
by proxy (3).
9.3.4
Strength of the Association
The magnitude of the observed association is useful to judge the likelihood that the exposure itself
affects the outcome and therefore the likelihood of a cause-effect relationship (168). The magnitude
of the observed associations only refers to the outcomes of Studies 3 and 4. In Study 3, the three
MR-preventive factors that were significantly associated with a reduction in MR episodes varied
from exp(B) = 0.36 to 0.54, both of which represents quite large effects, supporting the plausibility
of a cause-effect relationship. In Study 4, the six MR-preventive factors that confounded the
differing effects on MR use between Denmark and Norway varied between ∆exp(B) = 10% and
51% . Although these data are not as convincing as the MR-preventive factors in Study 3, they do
address some reasonable effects. A larger sample would nonetheless have been preferred, as
stronger associations and more significantly associated MR-preventive factors would likely have
followed.
9.3.5
Biological Credibility
The existence of a cause-and-effect relationship is supported if there is a known or postulated
biological mechanism by which the exposure might reasonably alter the outcome (168). Although
this definition is more relevant when the study concerns the risk of disease, some neurophysiological explanations concerning factors such as anxiety, fear, and aggression have accounted
for these emotions as a part of the MR-sequence (173). However, not enough data are available to
establish a cause-effect relationship based on biological credibility.
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9.3.6
Generalisability and Consistency
Generalisability refers to whether the results are applicable to other populations (168). The study
covered half of the eligible populations in Norway and Denmark: however, because we found no
systematic differences between the respondent and non-respondent groups, the results can
reasonably be assumed to cover these two populations. If compared to other populations (e.g., other
countries), differences in legislation, culture, practise, and other factors might cause overwhelming
obstacles to application. As the differences between Norway and Denmark were small, the present
results could perhaps be generalised by considering the differences between these countries and
other similar countries (e.g. Sweden or Finland). However, applying the results to other countries
would require a thorough examination of their cultures, legislation, and other relevant factors.
Consistency with other studies calls for comparisons with studies conducted in other populations,
by different investigators, at various times, and using alternative methodologies in a variety of
geographic and cultural settings (168). The findings of these studies are supported by many
international studies using different methodologies and by different investigators. However, if we
examine individual MR-preventive factors, the support and variation have not reached the level
required for “scientific proof” or consistency, possibly due to the complexity of the MR sequence.
9.4
Discussion of International High Quality Research
Five RCTs dealing with MR (coercion, MR, restraint, or seclusion) prevention were identified, as
follows:
Georgieva (174), “Reducing seclusion through involuntary medication: A randomised clinical
trial”: Although the use of involuntary medication was able to successfully reduce the number of
seclusions, alternative interventions are required to reduce the overall number and duration of
coercive incidents. The intervention involved the use of either seclusion or involuntary medication
as the first choice of intervention. This paper has been published after the initial literature review. In
Denmark, these guidelines have been described in the Danish Mental Health Act — the use of the
least intrusive intervention (6) — and generally medication, preferably voluntary, if not possible,
then involuntary, are considered less intrusive and hence the first choice before initiating MR. In
Norway, the principle of — the use of the least intrusive intervention — is also described in the
Norwegian Mental Healt Act (65), whether involuntary medication in practice are the first choice
before initiating MR is unknown, but the conclusion, that alternative interventions are needed to
reduce the overall number and duration of coercive incidents, complies to Norway as well.
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Berg (175), “A Randomised Controlled Comparison of Seclusion and Mechanical Restraint in
Inpatient Settings”: The result did not provide evidence for the use of one intervention over the
other. The conclusion was that, clinical decisions should account for patients preferences. The study
compared the restrictiveness of seclusion and MR from the patient´s point of view. This paper has
been published after the initial literature review. In Denmark, seclusion cannot be used; thus, taking
patient´s preferences into account, is not possible at the time being. In Norway patient´s
preferences, in this respect, may be taken into account, perhaps reducing the numbers of MR
episodes and increase the numbers of seclusion, thereby reducing the patients experiences of
restrictiveness.
Abderhalden (83), “Structured risk assessment and violence in acute psychiatric wards: randomised
controlled trial”: Structured risk assessment during the first days of treatment may contribute to
reduced violence and coercion (ed. forced acute tranquillising medication, seclusion and MR) in
acute psychiatric wards. The study investigated the implementation of BVC, which has been
implemented in more than 80% of “closed” units in Denmark. The amount of units that has
implemented the BVC in Norway, is unknown, but it is likely the same.
van de Sande (149), “Aggression and seclusion on acute psychiatric wards: effect of short-term risk
assessment”: The routine application of structured risk assessment measures was found to possibly
help reduce the incidents of aggression and the use of restraint and seclusion in psychiatric wards.
The study investigated the implementation of BVC in combination with Kenndy–Axic V. This
paper has been published after the initial literature review. As indicated above, more and more units
have implemented BVC in Denmark and Norway. Many units, also use the Global Assessment of
Functioning Scale, which is rather similar to Kenndy–Axic V, as both are brief clinician-scored
global assessment instruments used to measure the functioning of patients (176).
Putkonen (145), “Cluster-Randomised Controlled Trial of Reducing Seclusion and Restraint in
Secured Care of Men With Schizophrenia”: Seclusion and restraint were prevented without any
increase in violence on the wards for men with schizophrenia and violent behaviour. The study
investigated the implementation of the “Six Core Strategies”, as follows: leadership toward
organisational change, workforce support and development, the use of primary prevention tools, the
use of data to inform practice, debriefings, and meaningful consumer roles. This paper has been
published after the initial literature review. Parts of the “six core strategies” have been implemented
in Denmark and Norway, e.g. the use of risk assessment tools (use of primary prevention tools) and
some debriefing techniques, but most parts have not been implemented.
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These studies represent the highest international evidence available at this time. Comparing these
with the Danish and Norwegian MR-preventive initiatives in practise, as previously described, the
“Six Core Strategies” provide the best potential for developing MR-prevention practices in
Denmark and Norway. Comparing these strategies with the findings in Studies 3 and 4 of this
thesis, nearly all eight of the MR-preventive factors are components of the “Six Core Strategies”,
supporting the suggestion that the high evidence supporting implementation of the “Six Core
Strategies” could increase the overall causality of the eight identified MR-preventive factors or that
implementing of the “Six Core Strategies” might reduce the MR episodes in Denmark and Norway
as in a special setting in Finland (consistency). Although these five RCTs represent the highest
evidence available, none reached the highest grade of evidence. Furthermore, the settings in which
they were conducted only partially comply with the conditions of Danish and Norwegian
psychiatry.
10 Conclusions
10.1 Conclusions from the Individual Studies
Study 1: The objective of the first study was to answer the question: Which conditions in nursing
and which nursing interventions have been shown to reduce the frequency of mechanical restraint
episodes? No interventions reached the highest degree of recommendation combined with the
highest effect. Because no interventions reached the highest degree of recommendation (evidence),
the question cannot be answered with certainty. Therefore, the studies (Studies 3 and 4) conducted
later must include as many MR-preventive factors as possible, testing not only a few factors to be
effective in research settings (obtaining the highest recommendation grad), in practice (by
hypothesis tests, increasing the power of the later studies).
Study 2: The objective of the second study was: To compare the use of coercive measures on
psychiatric inpatients between Denmark and Sweden, Norway, Finland, Iceland, Belgium, The
Netherlands, United Kingdom, Ireland, France, and Italy, in order to share knowledge and learn
about what other countries do to minimize coercion. The study primarily revealed, that the many
differences in legislation between the countries and that very few countries, at the time of the study,
produced nationwide public data on coercive measures and background data, making the
comparison very difficult. Thereby, not reaching the objective on what to learn about what other
countries do to minimize coercion. Targeting the comparison between Denmark and Norway,
demonstrated a tendency for Norway to use less MR and physical restraint, than Denmark. Most
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other indicators were similar between the two countries. Thus, Norway was included in the later
studies (Studies 3 and 4). Overall, caution must be applied in the interpretation and comparison of
coercive measures and factors related to coercion between countries.
Study 3: The objective of the third study was to answer the question: How are presumed MRpreventive factors of nonmedical origin associated with the frequency of MR episodes in Denmark
and Norway? The results suggest that mandatory review, patient involvement, and crowding were
associated to a reduced frequency of MR episodes in Denmark and Norway. However, we were
unable to establish a causal effect between the reduction in MR episodes and these preventive
measures. Given that we included important potential confounders and that MR-preventive factors
have not been shown to present any adverse effects on the patients or staff in the literature, the
identified MR-preventive factors might be investigated further because they may contribute to a
better understanding of the phenomenon of MR.
Study 4: The objective of the fourth study was: To examine how presumed MR-preventive factors
of non-medical origin may explain the differing number of MR episodes between Denmark and
Norway. The results suggest that: the identification of patient’s crisis triggers; an increased number
of staff per patient; increased staff education; better work environment; and reduced substitute staff
use might explain why MR was initiated more often in Demark than in Norway. We cannot claim
that the implementation of these potential preventive measures, primarily in Denmark and in a few
units in Norway, would reduce the number of MR episodes. Given that we considered several
important potential confounders and that the MR-preventive factors demonstrated no adverse
effects on the patients or staff in the literature, the identified MR-preventive factors should be
investigated further because they may contribute to a better understanding of the phenomenon of
MR.
10.2 General Conclusions
The overall objective of this thesis was to generate knowledge of non-medical MR-prevention.
This thesis and the four included studies complement each other by using different means to
investigate specific preventive factors with the potential to minimise the number of MR episodes.
This thesis began with a systematic review of the literature to identify the most evident and
effective preventive MR factors. The practices in other countries were then examined, and Norway
was identified to be included in the later studies (Studies 3 and 4). Finally, specific MR-preventive
factors that could reduce the number of MR episodes in practice were investigated.
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These results have increased our understanding of the ability of specific MR-preventive factors to
reduce the number of MR episodes in Denmark and Norway, thereby generating knowledge in the
field of MR-prevention. These findings have not been identified via randomised controlled trials
(RCTs), and although some biases could be present, the questionnaire was thoroughly developed to
include several potential confounders. Furthermore, similar results have been demonstrated in
previous international studies. These factors are not likely to have adverse effects on the patients or
staff. Rather, the potential positive effects of these factors on the prevention of MR episodes may
reflect a general strengthening of the care and treatment environments. Therefore, further
investigation into the effects of implementing the following within Danish and Norwegian practices
is recommended: mandatory review, patient involvement, less crowding, higher staff education, less
substitute staff use, better work environment, increased number of staff per patient, and the
identification of the patient’s crisis triggers.
11 Perspectives
11.1 Clinical Implications
In Denmark the need to implement MR-preventive strategies is more urgent than ever; the number
of persons experiencing MR has never been higher, and the number of MR episodes is among the
highest over the 24 years of registration. Although, Norway uses less MR than Denmark, the
numbers has not decreased over the last decade; perhaps it even has a tendency to increase, making
the need for implementing MR-preventives strategies equally important.
First, though these studies addressed MR of inpatients in “closed” units, it would have been
preferred, that the patients had never become ill enough to require forceful/involuntary admission.
Thus, outpatient prevention, e.g., as joint crisis planning (177) or the use of the early recognition
method (166), should also be addressed in cooperation with the primary and secondary mental
health sectors. Another means of decreasing forced admission rates into “closed” units might be to
make it easier for patients to be voluntarily admitted.
Second, as shown in this thesis and as supported by other researchers (38;39;178;179), the
phenomenon of MR is multifaceted, and the reduction in the number of MR episodes thus requires
interventions in many different areas. Accordingly, many MR-preventive initiatives such as several
individual initiatives or programs encompassing several initiatives must be implemented in practise.
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Third, the selection process of MR-preventive factors to implement in practise should address both
those supported by the most obvious research and those most transferrable to Danish or Norwegian
conditions.
Fourth, any implementation of MR-preventive initiatives in practise must be followed by an
investigation of eventual adverse effects, e.g. injuries to patients or staff, rises in other coercive
measures, or the decreased psychological wellbeing of patients or staff.
The results from this thesis arise from a Danish and a Norwegian cohort; thus, although the
generalisability is acceptable, the grade of the evidence is not high, indicating that causality has not
been established. Thus, the clinical implications of the results of this thesis might include
investigating the effects and adverse effects of implementing a program containing the identified
MR-preventive factors in such a way that the effects of individual elements (organisational factors,
MR-preventive methods and tools), on the number of MR episodes can be addressed.
11.2 Future Research Recommendations
Although some RCTs have been conducted, they are biased due to the complex nature of the MR
phenomenon. Furthermore, three of these studies are cluster RCTs, and one of them involves
optional randomisation, because involuntary admitted patients in most countries cannot be included
in trials. This limitation suggests that a very well-designed and conducted RCT cannot by itself
reach the highest grade of recommendation; instead, this level of evidence requires several studies
be conducted before a meta-synthesis can be performed to reach the highest evidence grade.
Furthermore, the conducted RCTs should be transferrable to different Danish and Norwegian
settings.
Therefore, the future recommendations for research are to conduct more cluster RCTs in different
settings in Denmark and Norway on specific MR-preventive initiatives, methods, and tools such as
mandatory review, patient involvement, less crowding, higher staff education, less substitute staff
use, a better work environment, increased number of staff per patient, and the identification of the
patient’s crisis triggers. Also, conducting cluster RCTs, investigating programs or strategies
containing several of the before mentioned MR-preventive initiatives might be recommended.
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MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
12 Reference List
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67
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
13 Appendix
13.1 Appendix A
68
Combined effect
3
3
(87%)
Combined recommendation grade
2
Lykke J, Austin SF, Morch MM. Cognitive
milieu therapy and restraint within dual
diagnosis populations. Ugeskr Laeger 2008
Jan 28;170(5):339-43.
Thyrsting K, Hall EOC. Prevention of
coercion in psychiatric units: a secondary
analysis of a practitioner research project.
Klinisk sygepleje 2008;22(2):78-86.
Combined intervention
Fisher WA. Elements of successful restraint
programmes are effective in
and seclusion reduction programs and their
avoiding mechanical restraints e.g. application in a large, urban, state
patient participation, patient
psychiatric hospital. Journal of psychiatric
education, staff education,
practice 2003;9(1):7.
programmatic changes, high-level Hellerstein DJ, Staub AB, Lequesne E.
administrative endorsement,
Decreasing the use of restraint and seclusion
cultural changes, data analysis,
among psychiatric inpatients. Journal of
etc.
psychiatric practice 2007;(5):308-17.
Khadivi AN, Patel RC, Atkinson AR,
Levine JM. Association between seclusion
and restraint and patient-related violence.
Psychiatric Services 2004;55(11):1311-2.
Sullivan AM, Bezmen J, Barron CT, Rivera
J, Curley-Casey L, Marino D. Reducing
restraints: alternatives to restraints on an
inpatient psychiatric service--utilizing safe
and effective methods to evaluate and treat
the violent patient. Psychiatr Q
2005;76(1):51-65.
Taxis JC. Ethics and praxis: alternative
strategies to physical restraint and seclusion
in a psychiatric setting. Issues in Mental
Health Nursing 2002;23(2):157-70.
Implementation of patient-centred Fletcher E, Stevenson C. Launching the
care with a higher degree of
Tidal Model in an adult mental health
patients´ positive involvement in
programme. Nurs Stand 2001 Aug
their own care reduces the number 22;15(49):33-6.
Qualitative recommendation grade
Implementation of cognitive
milieu therapy reduces the number
of mechanical restraint episodes,
among other things through
patient involvement and
empowerment.
Quantitative recommendation grade
1
Reference
Qualitative evidence level
MR-preventive factor
Quantitative evidence level (effect)
No
Appraisal, Grading, and Combining the Recommendations of the MR-preventive Factors
4
3
3
1
3
N.a.
3
2
4
3
3
2
2
-2
(67%)
+2
(91%)
4
(52%)
-2
(72%)
4
(94%)
-2
(67%)
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
of mechanical restraint episodes.
4
5
6
The identification of the patients’
crisis triggers unique calming
techniques and decisions on
specific crisis interventions early
in the admission procedure,
thereby reducing the number of
mechanical restraints.
Introduction of validated risk
assessment systems including
suggestions of care interventions
reduce the number of mechanical
restraints.
Effective treatment of substance
abuse and psychosis reduces the
number of mechanical restraint
episodes; the treatment of mental
illnesses is also described
elsewhere in the review.
Sullivan D, Wallis M, Lloyd C. Effects of
patient-focused care on seclusion in a
psychiatric intensive care unit. Int J Ther
Rehabil 2004 Nov;11 2004;503-8.
Thyrsting K, Hall EOC. Prevention of
coercion in psychiatric units: a secondary
analysis of a practitioner research project.
Klinisk sygepleje 2008;22(2):78-86.
Jonikas JA, Cook JA, Rosen C, Laris A,
Kim JB. A program to reduce use of
physical restraint in psychiatric inpatient
facilities. Psychiatr Serv 2004
Jul;55(7):818-20.
McCain M, Kornegay K. Behavioral Health
Restraint: The Experience and Beliefs of
Seasoned Psychiatric Nurses. Journal for
Nurses in Staff Development
2005;21(5):236.
Meehan T, McIntosh W, Bergen H.
Aggressive behaviour in the high secure
forensic setting: the perceptions of patients.
Journal of Psychiatric and Mental Health
Nursing 2006;13(1):19-25.
Wynn R, Mykleburst LH. Patients´
Satisfaction and Self-Rated Improvement
Following Coercive Interventions.
Psychiatry, Psychology and Law
2006;13(2):199-202.
Abderhalden C, Dassen T, Fisher JE,
Halfens RJG, Haug HJ, Needham I.
Structured risk assessment and violence in
acute psychiatric wards: randomised
controlled trial. The British Journal of
Psychiatry 2008;193(1):44.
Cochrane-Brink KA, Lofchy JS, Sakinofsky
I. Clinical rating scales in suicide risk
assessment. General Hospital Psychiatry
2000;22(6):445-51.
Dernevik M, Grann M, Johansson S. Violent
behaviour in forensic psychiatric patients:
Risk assessment and different riskmanagement levels using the HCR-20.
Psychology, Crime & Law 2002;8(1):93111.
Fletcher E, Stevenson C. Launching the
Tidal Model in an adult mental health
programme. Nurs Stand 2001 Aug
22;15(49):33-6.
Palmstierna T, Olsson D. Violence from
young women involuntarily admitted for
severe drug abuse. Acta Psychiatrica
Scandinavica 2007;115(1):66-72.
Sullivan D, Wallis M, Lloyd C. Effects of
patient-focused care on seclusion in a
psychiatric intensive care unit. Int J Ther
Rehabil 2004 Nov;11 2004;503-8.
Thyrsting K, Hall EOC. Prevention of
coercion in psychiatric units: a secondary
analysis of a practitioner research project.
Klinisk sygepleje 2008;22(2):78-86.
(this paper ads very little to the synthesis)
-2
(36%)
2
+2
(50%)
4
3
3
3
2
N.a.
2
4
2
N.a.
4
3
3
4
-2
(–%)
-1
(27%)
-2
(–%)
3
(–%)
-2
(67%)
3
(–%)
-2
(36%)
–
69
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
7
8
70
Mandatory review from qualified
clinical experts, e.g. as postincident review minimizes the
number of mechanical restraint
episodes.
Better staff training reduces the
number of mechanical restraints
(longer duration of the training,
more staff participating, use of
different and involving education
methods, higher quality of the
content and greater diversity of
the topics, e.g. legislation, crisis
management, physical
intervention strategies,
antecedents, warning signs, deescalation techniques etc.).
Donat DC. Impact of a mandatory
behavioral consultation on
seclusion/restraint utilization in a
psychiatric hospital. Journal of Behavior
Therapy and Experimental Psychiatry 1998
Mar;29(1):13-9.
Prescott DL, Madden LM, Dennis M, Tisher
P, Wingate C. Reducing mechanical
restraints in acute psychiatric care settings
using rapid response teams. Journal of
Behavioral Health Services & Research
2007 Jan;34(1):96-105.
Bonner G, Lowe T, Rawcliffe D, Wellman
N. Trauma for all: a pilot study of the
subjective experience of physical restraint
for mental health inpatients and staff in the
UK. Journal of Psychiatric and Mental
Health Nursing 2002;9(4):465-73.
Bowers L, Nijman H, Allan T, Simpson A,
Warren J, Turner L. Prevention and
Management of Aggression Training and
Violent Incidents on UK Acute Psychiatric
Wards. Psychiatric Services
2006;57(7):1022.
Delaney KR, Johnson ME. Keeping the Unit
Safe: Mapping Psychiatric Nursing Skills.
Journal of the American Psychiatric Nurses
Association 2006 Aug 1;12(4):198-207.
Hahn S, Abderhalden C, Duxbury J, Halfens
RJG, Needham I. The effect of a training
course on mental health nurses' attitudes on
the reasons of patient aggression and its
management. Journal of Psychiatric &
Mental Health Nursing 2006;13(2):197-204.
Jonikas JA, Cook JA, Rosen C, Laris A,
Kim JB. A program to reduce use of
physical restraint in psychiatric inpatient
facilities. Psychiatr Serv 2004
Jul;55(7):818-20.
Lee S, Wright S, Sayer J, Parr A, Gray R,
Gournay K. Physical restraint training for
nurses in English and Welsh psychiatric
intensive care and regional secure units.
Journal of Mental Health 2001
Apr;10(2):151-62.
Mackay I, Paterson B, Cassells C. Constant
or special observations of inpatients
presenting a risk of aggression or violence:
nurses' perceptions of the rules of
engagement. Journal of Psychiatric &
Mental Health Nursing 2005;12(4):464-71.
Needham I, Dassen T, Halfens RJG, Haug
HJ, Fisher JE. The effect of a training
course in aggression management on mental
health nurses perceptions of aggression: a
cluster randomised controlled trial.
International Journal of Nursing Studies
2005;42(6):649-55.
Spokes K, Bond K, Lowe T, Jones J,
Illingworth P. HOVIS Hertfordshire/Oxfordshire violent incident
study. Journal of Psychiatric and Mental
Health Nursing 2002;9(2):199-209.
-2
(62%)
4
N.a.
4
3
4
3
3
4
-2
(36%)
4
3
(–%)
2
-2
(–%)
+2
(34%)
-2
(–%)
4
-1
(–%)
4
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
9
Staff attitudes such as positive
care for the patients, respect,
collaboration, communication,
humanism, empathy and less
control and involuntary
procedures, reduce the number of
mechanical restraints.
10 Higher staff-patient ratio reduces
the number of mechanical
restraints.
Wright S, Sayer J, Parr AM, Gray R,
Southern D, Gournay K. Breakaway and
physical restraint techniques in acute
psychiatric nursing: Results from a national
survey of training and practice. Journal of
Forensic Psychiatry & Psychology
2005;16(2):380-98.
Allen MH, Carpenter D, Sheets JL, Miccio
S, Ross R. What do consumers say they
want and need during a psychiatric
emergency? J Psychiatr Pract 2003
Jan;9(1):39-58.
Bowers L, Brennan G, Flood C, Lipang M,
Oladapo P. Preliminary outcomes of a trial
to reduce conflict and containment on acute
psychiatric wards: City Nurses. Journal of
Psychiatric & Mental Health Nursing
2006;13(2):165-72.
Bowers L, Alexander J, Simpson A, Ryan
C, Carr-Walker P. Student psychiatric
nurses' approval of containment measures:
relationship to perception of aggression and
attitudes to personality disorder.
International Journal of Nursing Studies
2007;44(3):349-56.
Cardell R, Pitula CR. Suicidal Inpatients'
Perceptions of Therapeutic and
Nontherapeutic Aspects of Constant
Observation. Psychiatric Services
1999;50(8):1066.
Duxbury J. An evaluation of staff and
patient views of and strategies employed to
manage inpatient aggression and violence
on one mental health unit: a pluralistic
design. Journal of Psychiatric and Mental
Health Nursing 2002;9(3):325-37.
Gillig PM, Markert R, Barron J, Coleman F.
A Comparison of Staff and Patient
Perceptions of the Causes and Cures of
Physical Aggression on a Psychiatric Unit.
Psychiatric Quarterly 1998;69(1):45-60.
Meehan T, McIntosh W, Bergen H.
Aggressive behaviour in the high secure
forensic setting: the perceptions of patients.
Journal of Psychiatric and Mental Health
Nursing 2006;13(1):19-25.
Robins CS, Sauvageot JA, Cusack KJ,
Suffoletta-Maierle S, Frueh BC. Special
Section on Seclusion and Restraint:
Consumers' Perceptions of Negative
Experiences and" Sanctuary Harm" in
Psychiatric Settings. Psychiatric Services
2005;56(9):1134.
Spokes K, Bond K, Lowe T, Jones J,
Illingworth P. HOVIS Hertfordshire/Oxfordshire violent incident
study. Journal of Psychiatric and Mental
Health Nursing 2002;9(2):199-209
Smith GM, Davis RH, Bixler EO, Lin HM,
Altenor A, Altenor RJ, et al. Special section
on seclusion and restraint: Pennsylvania
State Hospital System's seclusion and
restraint reduction program. Psychiatric
Services 2005;56(9):1115.
-2
(–%)
4
(–%)
4
4
4
4
4
N.a.
4
4
-2
(27%)
3
(–%)
4
3
(–%)
3
(–%)
4
4
4
3
(22%)
71
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
11 The higher educated staff, the
fewer episodes of mechanical
restraints.
12 The more experienced staff the
fewer episodes of mechanical
restraints.
72
Wynn R. Staff's attitudes to the use of
restraint and seclusion in a Norwegian
university psychiatric hospital. Nordic
Journal of Psychiatry 2003;57(6):453-9.
Delaney KR, Johnson ME. Keeping the Unit
Safe: Mapping Psychiatric Nursing Skills.
Journal of the American Psychiatric Nurses
Association 2006 Aug 1;12(4):198-207.
Flannery Jr RB, Stone P, Rego S, Walker
AP, Farley E. Characteristics of Staff
Victims of Patient Assault: 15-year Analysis
of the Assaulted Staff Action Program
(ASAP). Psychiatric Quarterly 2006.
Gim YS, Cheng SOB, Hong TL, Chin
MWB, Hen WH, Lee YJ. Nurses
experiences in identifying and managing
violence precipitants in a psychiatric inpatient setting. Singapore Nursing Journal
1999;26(1):21-4.
Mackay I, Paterson B, Cassells C. Constant
or special observations of inpatients
presenting a risk of aggression or violence:
nurses' perceptions of the rules of
engagement. Journal of Psychiatric &
Mental Health Nursing 2005;12(4):464-71.
Spokes K, Bond K, Lowe T, Jones J,
Illingworth P. HOVIS Hertfordshire/Oxfordshire violent incident
study. Journal of Psychiatric and Mental
Health Nursing 2002;9(2):199-209.
Bowers L, Jeffery D, Simpson A, Daly C,
Warren J, Nijman H. Junior staffing changes
and the temporal ecology of adverse
incidents in acute psychiatric wards. Journal
of Advanced Nursing 2007;57(2):153-60.
Delaney KR, Johnson ME. Keeping the Unit
Safe: Mapping Psychiatric Nursing Skills.
Journal of the American Psychiatric Nurses
Association 2006 Aug 1;12(4):198-207.
Flannery Jr RB, Stone P, Rego S, Walker
AP, Farley E. Characteristics of Staff
Victims of Patient Assault: 15-year Analysis
of the Assaulted Staff Action Program
(ASAP). Psychiatric Quarterly 2006.
Gim YS, Cheng SOB, Hong TL, Chin
MWB, Hen WH, Lee YJ. Nurses
experiences in identifying and managing
violence precipitants in a psychiatric inpatient setting. Singapore Nursing Journal
1999;26(1):21-4.
Mackay I, Paterson B, Cassells C. Constant
or special observations of inpatients
presenting a risk of aggression or violence:
nurses' perceptions of the rules of
engagement. Journal of Psychiatric &
Mental Health Nursing 2005;12(4):464-71.
Spokes K, Bond K, Lowe T, Jones J,
Illingworth P. HOVIS Hertfordshire/Oxfordshire violent incident
study. Journal of Psychiatric and Mental
Health Nursing 2002;9(2):199-209.
3
(–%)
2
4
3
3
5
4
3
3
5
-2
(–%)
3
(–%)
4
4
3
(–%)
2
-2
(–%)
3
(–%)
4
4
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
13 Limit-setting. If nurses change
their focus from considering the
patient as deviant to being a
resource in their own treatment it
would decrease the number of
mechanical restraint.
14 Early and adequate administration
of oral p.n. medication guided by
the individual patients´ problems,
medication experiences, and
preferences leads to fewer
mechanical restraint episodes.
Vatne S, Fagermoen MS. To correct and to
acknowledge: two simultaneous and
conflicting perspectives of limit-setting in
mental health nursing. J Psychiatr Ment
Health Nurs 2007 Feb;14(1):41-8.
Allen MH, Carpenter D, Sheets JL, Miccio
S, Ross R. What do consumers say they
want and need during a psychiatric
emergency? J Psychiatr Pract 2003
Jan;9(1):39-58.
Goedhard LE, Stolker JJ, Nijman HLI,
Egberts ACG, Heerdink ER. Aggression of
Psychiatric Patients Associated with the Use
of As-needed Medication.
Pharmacopsykiatry 2007;40(1):25.
McCain M, Kornegay K. Behavioral Health
Restraint: The Experience and Beliefs of
Seasoned Psychiatric Nurses. Journal for
Nurses in Staff Development
2005;21(5):236.
Meehan T, McIntosh W, Bergen H.
Aggressive behaviour in the high secure
forensic setting: the perceptions of patients.
Journal of Psychiatric and Mental Health
Nursing 2006;13(1):19-25.
Thapa PB, Palmer SL, Owen RR, Huntley
AL, Clardy JA, Miller LH. P.R.N. (Asneeded) orders and exposure of psychiatric
inpatients to unnecessary psychotropic
medications. Psychiatr Serv 2003
Sep;54(9):1282-6.
15 Debriefing, defusing and crisis
Bonner G, Lowe T, Rawcliffe D, Wellman
intervention minimize the number N. Trauma for all: a pilot study of the
of mechanical restraint episodes.
subjective experience of physical restraint
for mental health inpatients and staff in the
UK. Journal of Psychiatric and Mental
Health Nursing 2002;9(4):465-73.
Bowers L, Simpson A, Eyres S, Nijman H,
Hall C, Grange A, et al. Serious untoward
incidents and their aftermath in acute
inpatient psychiatry: the Tompkins Acute
Ward study. Int J Ment Health Nurs 2006
Dec;15(4):226-34.
Flannery Jr RB, Stone P, Rego S, Walker
AP, Farley E. Characteristics of Staff
Victims of Patient Assault: 15-year Analysis
of the Assaulted Staff Action Program
(ASAP). Psychiatric Quarterly 2006.
Jonikas JA, Cook JA, Rosen C, Laris A,
Kim JB. A program to reduce use of
physical restraint in psychiatric inpatient
facilities. Psychiatr Serv 2004
Jul;55(7):818-20.
16 Patients´ response to rules can be Alexander J. Patients' feelings about ward
positive and lead to fewer cases of nursing regimes and involvement in rule
mechanical restraint. For instance, construction. J Psychiatr Ment Health Nurs
if staff helps patients to
2006 Oct;13(5):543-53.
4
4
(–%)
N.a.
3
3
5
4
4
4
5
4
5
4
5
4
5
4
5
-2
(–%)
3
4
3
(–50%)
4
4
-2
(–%)
+2
(15%)
3
(–%)
73
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
understand not only the rules, but
also the rationale for the presence
of such rules. If the staff manages
to make patients understand that
the rules are imposed out of
concern for their welfare, then
patients may be less reluctant to
following these rules.
Duxbury J. An evaluation of staff and
patient views of and strategies employed to
manage inpatient aggression and violence
on one mental health unit: a pluralistic
design. Journal of Psychiatric and Mental
Health Nursing 2002;9(3):325-37 (this
paper ads only a little to the synthesis).
Gillig PM, Markert R, Barron J, Coleman F.
A Comparison of Staff and Patient
Perceptions of the Causes and Cures of
Physical Aggression on a Psychiatric Unit.
Psychiatric Quarterly 1998;69(1):45-60.
Meehan T, McIntosh W, Bergen H.
Aggressive behaviour in the high secure
forensic setting: the perceptions of patients.
Journal of Psychiatric and Mental Health
Nursing 2006;13(1):19-25.
Robins CS, Sauvageot JA, Cusack KJ,
Suffoletta-Maierle S, Frueh BC. Special
Section on Seclusion and Restraint:
Consumers' Perceptions of Negative
Experiences and" Sanctuary Harm" in
Psychiatric Settings. Psychiatric Services
2005;56(9):1134.
17 Activity-based nursing
Meehan T, McIntosh W, Bergen H.
interventions e.g. physical
Aggressive behaviour in the high secure
activities are effective in avoiding forensic setting: the perceptions of patients.
mechanical restraints.
Journal of Psychiatric and Mental Health
Nursing 2006;13(1):19-25.
Thomas B, Jones M, Johns P, Trauer T. Prn
medication use in a psychiatric highdependency unit following the introduction
of a nurse-led activity programme.
International Journal of Mental Health
Nursing 2006;15(4):266.
18 Several mental and physical
Bonner G, Lowe T, Rawcliffe D, Wellman
working environmental factors
N. Trauma for all: a pilot study of the
influence positively the number of subjective experience of physical restraint
mechanical restraints e.g.: Good
for mental health inpatients and staff in the
management as a high degree of
UK. Journal of Psychiatric and Mental
order, organisation or support,
Health Nursing 2002;9(4):465-73.
Adequate staffing, Psychiatric
Bowers L, Allan T, Simpson A, Jones J,
training, Rotation, Education, No Whittington R. Morale is high in acute
crowding, Emergency backup, etc. inpatient psychiatry. Soc Psychiatry
Several of these factors are
Psychiatr Epidemiol 2008 Jul 5.
described elsewhere in the review. Daffern M, Mayer M, Martin T. Staff
gender ratio and aggression in a forensic
psychiatric hospital. International Journal of
Mental Health Nursing 2006;15(2):93-9.
Owen C, Tarantello C, Jones M, Tennant C.
Violence and Aggression in Psychiatric
Units. Psychiatric Services
1998;49(11):1452.
Whittington D, McLaughlin C. Finding time
for patients: an exploration of nurses' time
allocation in an acute psychiatric setting.
Journal of Psychiatric & Mental Health
Nursing 2000;7(3):259-68.
19 Less crowding e.g. less stimuli,
Meehan T, McIntosh W, Bergen H.
less environmental stress and
Aggressive behaviour in the high secure
more personal space decrease the forensic setting: the perceptions of patients.
number of mechanical restraints.
Journal of Psychiatric and Mental Health
Nursing 2006;13(1):19-25.
74
3
(–%)
3
(–%)
4
4
4
4
5
4
5
4
4
5
4
5
4
4
5
4
5
+2
(–%)
-2
(–%)
3
(–%)
4
(–%)
3
(–%)
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
Vaaler AE, Morken G, Fløvig JC, Iversen
VC, Linaker OM. Effects of a psychiatric
intensive care unit in an acute psychiatric
department. Nordic Journal of Psychiatry
2006;60(2):144-9.
20 Higher regular staff and lower
Bonner G, Lowe T, Rawcliffe D, Wellman
substitute ratio reduce the number N. Trauma for all: a pilot study of the
of mechanical restraints.
subjective experience of physical restraint
for mental health inpatients and staff in the
UK. Journal of Psychiatric and Mental
Health Nursing 2002;9(4):465-73.
Bowers L, Allan T, Simpson A, Nijman H,
Warren J. Adverse Incidents, Patient Flow
and Nursing Workforce Variables on Acute
Psychiatric Wards: The Tompkins Acute
Ward Study. International Journal of Social
Psychiatry 2007;53(1):75.
Spokes K, Bond K, Lowe T, Jones J,
Illingworth P. HOVIS Hertfordshire/Oxfordshire violent incident
study. Journal of Psychiatric and Mental
Health Nursing 2002;9(2):199-209.
(this paper ads only a little to the synthesis).
21 Staffs´ opposition towards
Lind M, Kaltiala-Heino R, Suominen T,
mechanical restraint, due to the
Leino-Kilpi H, Valimaki M. Nurses'ethical
perception that mechanical
perceptions about coercion. Journal of
restraint is ethically problematic,
Psychiatric & Mental Health Nursing
decrease the number of
2004;11(4):379-85.
mechanical restraints.
Van Doeselaar M., Sleegers P,
Hutschemaekers G. Professionals' attitudes
toward reducing restraint: the case of
seclusion in the Netherlands. Psychiatr Q
2008 Jun;79(2):97-109.
22 Alarm systems e.g. video
D'Orio BM, Purselle D, Stevens D, Garlow
surveillance and radio systems and SJ. Reduction of episodes of seclusion and
well trained response teams,
restraint in a psychiatric emergency service.
reduce the number of mechanical Psychiatric Services 2004;55(5):581-3.
restraints.
23 Better care-alliance between
Wynn R. Staff's attitudes to the use of
patients and the nursing staff
restraint and seclusion in a Norwegian
reduces the number of mechanical university psychiatric hospital. Nordic
restraints.
Journal of Psychiatry 2003;57(6):453-9.
24 Communication especially
Duxbury J, Whittington R. Causes and
communicative de-escalation
management of patient aggression and
reduces the number of mechanical violence: staff and patient perspectives.
restraint episodes.
Journal of Advanced Nursing 2005
Jun;50(5):469-78.
25 Well-maintained and familiar
Vaaler AE, Morken G, Linaker OM. Effects
surroundings reduce the number
of different interior decorations in the
of mechanical restraints.
seclusion area of a psychiatric acute ward.
Nordic Journal of Psychiatry 2005;59(1):1924.
26 Music as diversion and relaxation Janelli LM, Kanski G. Music for untying
before and after mechanical
restrained patients. Journal of the New York
restraint reduces the number of
State Nurses Association 1998;29(1):13-5.
mechanical restraint episodes.
27 Separation of acutely disturbed
Meehan T, McIntosh W, Bergen H.
patients reduces the number of
Aggressive behaviour in the high secure
mechanical restraint episodes.
forensic setting: the perceptions of patients.
Journal of Psychiatric and Mental Health
Nursing 2006;13(1):19-25.
(This factor is graded, in the review as 5, it
should have been 4).
No refers to the number in the hierarchy for which 1 is highest/best.
-2
(–%)
4
4
5
4
5
4
N.a.
4
5
+2
(16%)
4
N.a.
4
5
-2
(–%)
4
N.a.
4
5
-3
(–%)
4
N.a.
4
5
+2
(–%)
4
N.a.
4
5
4
(–%)
4
N.a.
4
5
N.a.
5
5
5
3
(–%)
4
-2
(–%)
-2
(–%)
4
75
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
Factor refers to synthesized description of the MR-preventive factor. The final synthesis was guided by the following three
questions: Which interventions match patients’ views and experiences? Which interventions have yet to be evaluated in clinical
settings? Does the effect of the intervention seem plausible from a clinical point of view?
Reference refers to the literature reference in Vancouver style.
Quantitative evidence level describes the appraisal of individual quantitative papers. Appraising the quantitative research papers was
conducted as outlined by the Danish Reference Programme Secretariat (Sekretariatet for Referenceprogrammer, 2004), Method for
Evaluating Research and Guideline Evidence (MERGE; Liddle et al., 1996), and SIGN (Harbour, 2008); 1++, 1+, 1-, 2++, 2+, 2-, 3,
4, where 1++ is the best level. Checklists for evaluating the methodological quality of the papers can be acquired from the authors. In
brackets, the reduction in the number of mechanical restraints (in a few cases combined MR and seclusion rates) is displayed as a
percentage, if the reduction was caused by more than one intervention, it was downgraded accordingly. – describes no available
figures.
Qualitative evidence level describes the appraisal of individual qualitative papers. Appraising the qualitative research papers was
conducted as outlined by Sandelowski and Barroso (2007). The papers were rated according to the complexity levels by Kearney in
which 1 = dense explanatory description, 2 = depiction of experimental variation, 3 = shared pathway or meaning, 4 = descriptive
categories, 5 = findings restricted by a priori frameworks (level 5 papers were excluded), 1 is the “best” level. The checklist for
evaluating the methodological quality of the papers can be required from the author.
Quantitative recommendation grade from 1 to 5, in which 1 is the highest/best. N.a. refers to no available paper. The hierarchy of
the quantitative grading was developed from the DRPS (2004, NERGE (1996), and SIGN (2008).
Qualitative recommendation grade from 1 to 5, for which 1 is the highest/best. N.a. referred to no available paper. The hierarchy of
the qualitative grading can be found below.
Combined recommendation grade describes the whole body of evidence regarding the level of scientific “truth” or its potential for
clinical application of a specific intervention ranked from 1 to 5, for which 1 is the highest/best. Combining the quantitative and
qualitative recommendations was conducted by taking the better of the two.
Combined effect refers to the reduction in the number of MRs, from 1 to 5, with 1 being the best (80% to 100% reduction), 2
representing a reduction of 60% to 80% and so on. These were combined as follows: no paper, the level was set to 5 (0–20%
reduction); one paper, the level was directly transferred; two or more papers, the level was influenced by: (1) the paper with the best
recommendation grade, (2) the paper best describing the intervention, and (3) a simple average.
Assessment system for quantitative research
Evaluation criteria for the study (paper)
(MERGE-1996)
Evaluation criteria are coded according to the extent to which the criteria in the specific checklist
are fulfilled:
Criterion entirely fulfilled.
Criterion mostly fulfilled.
Criterion mostly not fulfilled.
Criterion not at all fulfilled.
Criterion not described adequately to classify as a, b1, b2 or c.
Criterion not applicable.
Overall assessment of the study (paper)
(DRPS-2004)
This table is used to assess the general methodological quality of the study, in three grades:
All or the most criterion are fulfilled. Criterion witch are not fulfilled, will very rarely change
the conclusions of the study.
Some criterions are fulfilled. Criterion witch are not fulfilled or thorough described, will rarely
change the conclusions of the study.
Few or none criterions are fulfilled. The conclusions of the study can easily change.
1++
1+
12++
76
Code
a
b1
b2
c
?
n/a
Code
++
+
-
Levels of evidence for quantitative studies
(Insp. from SIGN-2008, MERGE-1996 and DRPS-2004)
High-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias or Controlled trials
without randomisation.
High-quality systematic reviews of case–control or cohort studies
High-quality case–control or cohort studies with a very low risk of confounding, bias or chance and a
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
2+
2-
3
4
1
2
3
4
5
high probability that the relationship is causal.
Well-conducted case–control or cohort studies or multiple time series or before and after studies
(Preferably from more than one centre or research group) with a low risk of confounding, bias or
chance and a moderate probability that the relationship is causal. Diagnostic tests (diagnostic
method).
Case–control or cohort studies or multiple time series or before and after studies with a high risk of
confounding, bias, or chance and a significant risk that the relationship is not causal. High quality
descriptive studies. Diagnostic tests (Nosographic method).
Moderate quality descriptive studies.
Case reports, case series, decision analyses.
Expert opinion. Formal consensus. Low quality descriptive studies.
Grades of recommendation for quantitative research
(Insp. from SIGN-2008, MERGE-1996 and DRPS-2004)
At least one meta-analysis, systematic review or RCT rated as 1++, and directly applicable to the
target population, or a systematic review of RCTs or a body of evidence consisting principally of
studies rated as 1+, directly applicable to the target population and demonstrating overall consistency
of results.
A body of evidence including studies rated as 1- and 2++, directly applicable to the target population
and demonstrating overall consistency of results, or extrapolated evidence from studies rated as 1++
or 1+.
A body of evidence including studies rated as 2+, directly applicable to the target population and
demonstrating overall consistency of results, or extrapolated evidence from studies rated as 2++.
A body of evidence including studies rated as 2- or 3, directly applicable to the target population and
demonstrating overall consistency of results, or extrapolated evidence from studies rated as 2+.
Opinions of respected authorities, based on clinical experience, or reports of expert committees rated
as 4.
Assessment system for qualitative research
Evaluation criteria for the study (paper)
(Sandelowski and Barroso – 2007)
Evaluation criteria are coded according to the extent to which the criteria in the specific checklist
are fulfilled:
Presence
Relevance
Overall assessment of the study (paper)
(Sandelowski and Barroso – 2007)
This table is used to evaluate the quality of the study:
Acceptable (Signal > noise)
Questionable (Noise > signal)
Code
+/+/-
Code
+
-
Levels of evidence for qualitative studies
(Kearny – 2004)
No
1
Description
Notes
Dense explanatory The highest level of complexity and discovery might be termed the qualitative gold
description
standard. These findings may be seen as representing the characteristics of the “experiential
variation” category, when achieved to the highest degree, but in doing so, these findings
appear qualitatively different. Clifford Geertz (1973) exemplified this level of findings in
his definition of “thick description,” but this level of explanatory detail can be seen outside
ethnography as well. These findings are a rich evocation of a situated understanding of a
multifaceted and varied human phenomenon in a unique situation. With dense factual and
descriptive detail, they portray the full depth and range of complex influences that propel
77
MECHANICAL RESTRAINT – PREVENTIVE FACTORS IN THEORY AND PRACTICE
2
3
4
5
persons to make one choice over another, to speak one way versus another, and to view life
one way rather than another. Physical and social context is colorfully conveyed, and the
experience of time is captured at the levels of social, cultural, and political history as well
as at the level of personal progress. The role of the researcher in this particular context and
interaction also is clearly apparent. Dense explanatory description may be achieved using a
number of qualitative methods including ethnography, phenomenology, and grounded
theory.
Depiction of
An even greater degree of qualitative complexity is achieved in findings that not only
experiential
describe the main pathway or essence of an experience but also portray how that
variation
experience or pathway varies depending on individuality and context. Portraying or
explaining variation in a human experience requires considerable breadth and depth of
sampling and data collection and a high level of analytic expertise, which can produce a
high degree of discovery of new insights or perspectives on human phenomena. Although
grounded theories are the type of findings most commonly thought of as portraying
variation, this level of complexity can be seen in other approaches as well. The rich detail
in a fully realized phenomenology or ethnography can capture a variety of viewpoints and
realizations of a human experience and the contextual sources of that variety, whether
political, cultural, familial, or intrapersonal.
Shared pathway or The third category shows an increase in complexity. Here, the investigator's interpretation
meaning
produces a synthesis of a shared experience or process. It is distinguished from the
previous grouping by the investigator's integration of concepts or themes into a linked and
logical portrayal. The commonality, core, or essence of the experience is captured by the
analyst. This synthesis has the potential to reveal something previously undescribed about
the phenomenon that would not be readily apparent in a series of unlinked categories.
The increased complexity enables greater discovery. Shared pathways or meanings can be
seen in findings achieved with a variety of qualitative approaches. For example, in a
qualitative description, data clusters are linked in a holistic picture of the experience. In a
grounded-theory study, concepts are connected in a model of influences and strategies or
actions, with each relationship substantiated by data. In a phenomenological study, themes
are experiential components integrated into a narrative depiction of a multifaceted
phenomenon. The analyst has moved from describing parts of a data set to explaining how
these are components of a larger social or experiential whole.
Descriptive
The simplest level of complexity of qualitative evidence, but one that nonetheless may
categories
portray discovery is a series of labelled data categories. Clusters of data are labelled with
brief headings that indicate the topic or type of data contained therein, as in a book's table
of contents. Content analysis techniques often produce findings in this format.
Findings restricted Findings that are produced by applying an existing set of ideas to qualitative data without
by a priori
identifying new insights or enriching, extending, or revising existing theory may offer a
frameworks
certain degree of complexity but little discovery, and consequently they provide little or no
evidence for practice.
Grades of recommendation for qualitative research
(Insp. by Sandelowski and Barroso – 2007, Kearney – 2004, MERGE – 1996, DRPS – 2004, and SIGN – 2008)
At least one high quality meta-synthesis, systematic review or meta-summary rated as 1 and directly applicable
1
to the target population and context, or a body of evidence consisting principally of papers rated as 1, directly
applicable to the target population and context and demonstrating overall consistency of findings.
A body of evidence including papers rated as 2 or one paper rated as 1, directly applicable to the target
2
population and context and demonstrating overall consistency of findings, or extrapolated evidence from papers
rated as 1.
A body of evidence including papers rated as 3 or one paper rated as 2, directly applicable to the target
3
population and context and demonstrating overall consistency of findings, or extrapolated evidence from papers
rated as 2.
A body of evidence including papers rated as 4 or one paper rated as 3, directly applicable to the target
4
population and context and demonstrating overall consistency of findings.
One or two papers rated as 4.
5
78
Paper 1
Mechanical Restraint
Which Interventions Prevent Episodes of Mechanical Restraint?
A Systematic Review.
Perspectives in Psychiatric Care
ISSN 0031-5990
Mechanical Restraint—Which Interventions Prevent Episodes
of Mechanical Restraint?—A Systematic Review
ppc_307
83..94
Jesper Bak, RN, SD, MPH, Stud. PhD, Mette Brandt-Christensen, MD, PhD,
Dorte Maria Sestoft, MD, PhD, and Vibeke Zoffmann, RN, MPH, PhD
Jesper Bak, RN, SD, MPH, Stud. PhD, is a Head Nurse, Mental Health Centre Sct. Hans, Roskilde, Denmark; Mette Brandt-Christensen, MD, PhD, is
Employed Senior Consultant, Forensic Psychiatric Centre Glostrup, Copenhagen, Denmark; Dorte Maria Sestoft, MD, PhD, is Head of Department,
Ministry of Justice, Clinic of Forensic Psychiatry, Copenhagen, Denmark; and Vibeke Zoffmann, RN, MPH, PhD, is a Senior Researcher, Steno Diabetes
Center, Gentofte, Denmark.
Search terms:
Mechanical restraint, mental disorder, nursing,
psychiatry, systematic review
Author contact:
[email protected], with a copy to the
Editor: [email protected]
Conflict of Interest Statement
The authors report no actual or potential
conflicts of interest. No external or intramural
funding was received.
PURPOSE: To identify interventions preventing mechanical restraints.
DESIGN AND METHODS: Systematic review of international research papers
dealing with mechanical restraint. The review combines qualitative and quantitative
research in a new way,describing the quality of evidence and the effect of intervention.
FINDINGS: Implementation of cognitive milieu therapy, combined interventions,
and patient-centered care were the three interventions most likely to reduce the
number of mechanical restraints.
PRACTICE IMPLICATIONS: There is a lack of high-quality and effective intervention studies. This leaves patients and metal health professionals with uncertainty
when choosing interventions in an attempt to prevent mechanical restraints.
First Received August 11, 2010; Final Revision
received February 10, 2011; Accepted for
publication February 18, 2011.
doi: 10.1111/j.1744-6163.2011.00307.x
In some countries, mechanical restraint is performed according to the law when psychiatric inpatients pose a risk to themselves or to others (Indenrigs- og Sundhedsministeriet, 2006).
Other countries do not allow the use of mechanical restraint;
for example, in the United Kingdom, only the use of seclusion
and holding (physical restraint) is allowed (except in exceptional circumstances in special hospital environments).
Therefore, what constitutes the use of mechanical restraint
differs a lot across Europe and the rest of the world. Nursing
staff has the primary role in carrying out the practical procedure. Leather or fiber belts are used to fixate the patient to the
bed, occasionally together with straps around the hands and
feet. In this paper, mechanical restraint is defined: The use of
restraining straps, belts, or other equipment to restrict movement, as suggested by Bowers, van der Werf, et al. (2007). Even
though mechanical restraint is used within the law, thorough
ethical considerations regarding patients’ right of selfdetermination and human rights, in general, should be made
on how much this intervention should be used. The European
Committee for the Prevention of Torture and Inhuman or
Degrading Treatment or Punishment has, after visits to
Denmark, even stated that applying instruments of physical
restraint to psychiatric patients for days cannot have any
medical justification and amounts to ill treatment (The EuroPerspectives in Psychiatric Care 48 (2012) 83–94
© 2011 Wiley Periodicals, Inc.
pean Committee for the Prevention of Torture and Inhuman
or Degrading Treatment or Punishment, 2002; Hauksson,
2008). Physically, applying mechanical restraints is a risky
intervention where patients can develop deep vein thromboses, pulmonary embolisms, and lactic acidosis, which
could contribute to cardiovascular collapse, broken bones,
etc. (Chan, Neuman, Clausen, Eisele, & Vilke, 2004; Hem,
Steen, Opjordsmoen, & Moussaoui, 2001; Hick, Smith, &
Lynch, 1999; Laursen, Jensen, Bolwig, & Olsen, 2005; Morrison & Sadler, 2001; Nielsen, 2005). Against this are also the
negative psychological impact of mechanical restraint on
patients feeling helpless, angry, trapped, sad, fearsome,
unpleasant, or offended, and patients often regard it as an
injustice or see it as punishment, in the worst case developing
lifetime trauma and possibly post-traumatic stress disorder
(Bower, McCullough, & Timmons, 2003; Cusack, Frueh,
Hiers, Suffoletta-Maierle, & Bennett, 2003; Frueh et al., 2005;
Steinert, Bergbauer, Psych, Schmid, & Gebhardt, 2007). These
negative consequences are inconsistent with healthcare providers’ basic attitudes regarding“doing good”for the patients.
Weighty arguments for using mechanical restraint are,
however, that staff members have to allow for the patient’s
own health and life, as well as the health, lives, and rights of
others, for example, violence toward fellow patients, relatives,
83
Mechanical Restraint—Which Interventions Prevent Episodes of Mechanical Restraint?—A Systematic Review
and staff. Altogether, the dilemma is not easily solved, but it is
widely agreed that the number of mechanical restraints
should be reduced as much as possible (Sundhedsstyrelsen,
2009).
Scientists and clinicians agree that many factors influence
the complex phenomenon of mechanical restraint. The
factors, which influence the aggressive or self-destructive
behavior of the patient and, secondarily, the frequency of
restraints inside a psychiatric ward, could be relative to the
patient, ward, and staff, or to“situational/interactional condition” (Nijman, Campo, Ravelli, & Merckelbach, 1999). Many
of these factors are related to daily activities when socializing
with other persons in the psychiatric ward. Daily living is the
area where nurses and other nursing staff members have a
crucial role in reducing the use of mechanical restraint. Also,
the rate of coercive interventions is, in many countries, considered an indicator of the quality of psychiatric inpatient
treatment (Institut for Kvalitet og Akkreditering i Sundhedsvæsenet, 2009). However, research into the type of nursing
interventions required, to prevent episodes of mechanical
restraint, is scarce (Leitner, Barr, Jones, McGuire, & Whittington, 2006; National Institute for Health and Clinical Excellence [NICE], 2004, 2005).
Numerous actions are recommended in order to reduce the
use of mechanical and physical restraint: risk management;
physical environment and alarm systems; staff attitudes and
care alliance; prediction: antecedents, warning signs, and risk
assessment; training, education, skills, and competencies;
working with psychiatric patients; de-escalation methods and
techniques; post-incident review; and staff environmental
factors, both mental and physical working environment;
medication; effective treatment of illness and abuse; effective
observation; and physical training (Department of Health,
2007; NICE, 2005). Though, locally, some of these actions
have been shown to reduce the numbers of restraint (Fisher,
2003; Hellerstein, Staub, & Lequesne, 2007), the nationwide
figures still fail to decrease in some countries (Bremmes,
Hatling, & Bjørngaard, 2008; Sundhedsstyrelsen, 2008).
Purpose
In order to provide a basis for choosing and developing
nursing interventions, under which the number of mechanical restraint episodes are decreased, the following will be
reviewed:
Which conditions in nursing and which nursing
interventions have been shown to reduce the frequency
of mechanical restraint episodes?
Table 1. Stages of the Review Process
Developing scope of the review.
Developing review questions with clinical focus, and inclusion and
exclusion criteria.
Developing search strategy and search phrases.
Identifying sources of evidence.
Carrying out the searches.
Sifting the evidence.
Extracting relevant data from studies meeting methodological and
clinical criteria.
Evaluating methodological quality using relevant checklists.
Compiling papers in relevant evidence tables.
Interpreting and grading each paper.
Abstracting interventions and summarizing intervention levels.
Grading the recommendations for the quantitative and qualitative
evidence separately.
Summarizing the whole body of evidence.
Drawing up presentation of the result.
Formulating conclusions and implications for further research.
Drawing up the review article.
were found (Muralidharan & Fenton, 2006). Therefore,
searches were not limited to these study designs. Also, many of
the areas under investigation could not be covered from
quantitative papers solely. Therefore, we developed a way to
combine quantitative and qualitative papers into ranked recommendations in order to deduce maximum information
from the available papers.
Theory
The method was based on principles outlined by the Danish
Reference Programme Secretariat (Sekretariatet for Referenceprogrammer, 2004) and NICE (2007) involving evaluation
of the quantitative research; by Sandelowski and Barroso
(2007) and Kearney (2001) involving evaluation of the qualitative research; and by Scottish Intercollegiate Guidelines
Network (SIGN; Harbour, 2008) inspiring the process of the
combined evaluation of both qualitative and quantitative
research. The combination of principles from the mentioned
sources has been necessary because no one in itself covered
both quantitative and qualitative research quantification. The
stages of the review process can be found in Table 1.
Inclusion Criteria
Original peer-reviewed papers, covering the care of adult psychiatric inpatients who have been physically restrained, were
included in the review. The interventions and conditions
covered in the review can be found in Table 2.
Design and Methods
Exclusion Criteria
It was recognized very early during the process that only very
few randomized clinical trials existed, and no meta-analyses
Reviews were excluded to avoid some papers to be included
twice or more, spoiling the calculations of effect and recom-
84
Perspectives in Psychiatric Care 48 (2012) 83–94
© 2011 Wiley Periodicals, Inc.
Mechanical Restraint—Which Interventions Prevent Episodes of Mechanical Restraint?—A Systematic Review
Table 2. Interventions and Conditions Covered
Care Pathways (MR Sequence)
Fundamental causes (psychosis,
conflicts, abuse)
Negative aggressive feelings.
Toward the patient
himself/herself or toward
others.
Negative aggressive actions.
Toward the patient
himself/herself or toward
others.
The mechanical restraint. Framework and
aftercare/prevention.
Interventions and Conditions
Fundamental causes:
• Degree of illness and
substance abuse
• Working with psychiatric patients,
for example, in environment
therapy or using nursing theory
• Background variables such as
diagnosis, gender distribution,
ethnicity, types of staff being
injured, reasons for being
mechanically restrained, etc.
Negative aggressive feelings:
• Patients’ and relatives’
knowledge, feelings, and
attitudes
• Staff attitudes and care
alliance
• Prescription and use of p.n.
medication, administered
by nurses
Negative aggressive actions:
• Prediction such as
antecedents, warning
signs, and risk assessment
• De-escalation methods and
techniques
• Observation
• Limit setting
The mechanical restraint:
• Alarm systems
• Physical environment
• Physical staff training
• Debriefing, defusing, or post-incident
reviews (patients and staff)
• Potential health risk because of MR
• Staff training, education, skills, and
competencies
• Staff environmental factors, both mental
and physical working environment
MR, mechanical restraint; p.n., pro necessitate (as needed).
mendation. Papers describing interventions and conditions
to prevent physical restraint in nonpsychiatric inpatient settings, learning disability settings, nursing homes, and prisons
were excluded.
Time Frame
The study included papers published after 1998. The papers
were obtained between August and November 2008, with an
update in April 2009.
Search Strategies
The searches included English, Danish, Norwegian, and
Swedish language citations, all with English abstracts.
Key words used in different combinations and inflections
in the search were active, admitted, adolescence, affect, aged,
aggression, alarm, and alliance, and the antecedents were
anxiety, appreciative, atmosphere, attitude, bipolar, care
plan, check, child, committed, communication, coping,
debriefing, de-escalation, delusion, depression, detained,
diffusion, developmental disability, disorder, diversion, dual
diagnosis, education, elder, environmental therapy, forensic,
hospitalised, house rule, hypo, hysterical, impulse, inpatient,
intervention, learning disability, manage, manic, medication, mental health, milieu, mood, music, nonaversive,
nonconfrontational, nursing, nursing home, nursing theory,
observation, old, one on one, one to one, outpatient, panic,
paranoid, personality disorder, pharmacology, physical,
prediction, prevention, prison, p.r.n./p.n. (pro re nata/
pro necessitate—as needed or as the situation arises)
medication, psychiatry, rapid tranquillisation, rehabilitation, reorganizing, restraint, review, risk assessment, schizophrenia, seclusion, strategy, surveillance, talk down, therapy,
time out, training, treatment, violence, warning signs, and
young.
The structure of the search strategy is:
• An overarching strategy for conditions and interventions
across selected databases
• A search to identify guidance and reports, for example, governmental reports, not indexed in the major databases
• A topic-specific search strategy on PubMed
• For each condition or intervention, evidence of effectiveness or harm was sought
• Manual searching was performed in key areas not electronically indexed (e.g., PhD thesis)
• Reference lists of the most relevant papers were checked for
articles not otherwise found.
One example from the searches is provided below in
Table 3; the whole search strategy, from the 32 databases, can
be required from the authors.
Table 3. Example of a Search String
CINAHL and AMED/EBSCOhost: (Restrained OR Restraint OR Restraints OR Secluded OR Seclusion OR (“restraint”)) or (MH “Psychiatry”) not
(Nursing-home OR Prison OR Learning-disability OR Learning-disabilities OR Rehabilitation OR Outpatient OR developmental-disability OR
developmental-disabilities), Limiters Applied, Publication Year from: 1998-; Inpatients; Age Groups: Adult, 19–44 years, Middle Age, 45–64 years.
Perspectives in Psychiatric Care 48 (2012) 83–94
© 2011 Wiley Periodicals, Inc.
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Mechanical Restraint—Which Interventions Prevent Episodes of Mechanical Restraint?—A Systematic Review
Table 4. Grades of Recommendation for Qualitative Research
1 At least one high-quality meta-synthesis, systematic review, or meta-summary rated as 1 and directly applicable to the target population and
context, or a body of evidence consisting principally of papers rated as 1, directly applicable to the target population and context, and
demonstrating overall consistency of findings.
2 A body of evidence including papers rated as 2 or one paper rated as 1, directly applicable to the target population and context, and demonstrating
overall consistency of findings, or extrapolated evidence from papers rated as 1.
3 A body of evidence including papers rated as 3 or one paper rated as 2, directly applicable to the target population and context, and demonstrating
overall consistency of findings, or extrapolated evidence from papers rated as 2.
4 A body of evidence including papers rated as 4 or one paper rated as 3, directly applicable to the target population and context, and demonstrating
overall consistency of findings.
5 One or two papers rated as 4.
The papers were rated according to the complexity levels by Kearney where 1 = dense explanatory description, 2 = depiction of experimental variation, 3
= shared pathway or meaning, 4 = descriptive categories, 5 = findings restricted by a priori frameworks (level 5 papers were excluded).
The basic assumption for the recommendation model was that the greater complexity and discovery, the more trustworthy the evidence was, and the
more researchers that found independently the same finding (here intervention), the more reason there was to believe that it would work in the clinical
setting.
If the evidence was not directly applicable to the target population and context, it was downgraded.
Checklists and Evidence Tables
Checklists for evaluating the methodological quality of the
papers and evidence tables for compiling studies can be
required from the authors (Critical Appraisal Skills Programme, 2006; Health Care Practice Research and Development Unit, 2005; Kearney, 2001; Liddle, Williamsom, &
Irwing, 1996; NICE, 2007; Sandelowski & Barroso, 2007; Sekretariatet for Referenceprogrammer, 2004).
Evidence Grading
Quantitative Research Grading. Once individual papers had
been assessed for methodological quality and relevance in
terms of the clinical questions, they were graded according
to the levels of evidence. The available evidence for each
intervention/condition was then compiled into tables.
Grading of quantitative research papers was conducted as
outlined by the Danish Reference Programme Secretariat
(Sekretariatet for Referenceprogrammer, 2004). Because of
the small number of eligible quantitative studies, it was not
possible to perform meta-analyses. The levels of evidence and
grades of recommendation (the grade of recommendation
describes the whole body of evidence regarding a specific
quantitative or qualitative topic [here interventions] and its
ability to influence the phenomenon, “mechanical restraint,”
in the clinical setting) were developed from the Danish Reference Programme Secretariat (Sekretariatet for Referenceprogrammer, 2004), Method for Evaluating Research and
Guideline Evidence (MERGE; Liddle et al., 1996), and SIGN
(Harbour, 2008); the developed descriptions can be required
from the authors.
Qualitative Research Grading. Once individual papers had
been assessed for methodological quality and relevance in
terms of the clinical questions, they were graded according to
86
the levels of complexity in the evidence described by Kearney
(2001) (Kearney argues that: “The greater the complexity and
discovery within qualitative findings, the stronger may be the
potential for clinical application”). The available evidence
was then compiled into tables. Appraising the qualitative
research papers was conducted as outlined by Sandelowski
and Barroso (2007). The new hierarchy of the recommendation grades for the qualitative evidence was developed for this
review by the first author, Jesper Bak, in order to provide a
united and structured evidence base. The development
was inspired by Kearney, Sandelowski, and Barroso, the
Danish Reference Programme Secretariat (Sekretariatet for
Referenceprogrammer, 2004), MERGE (Liddle et al., 1996),
and SIGN (Harbour, 2008); the developed hierarchy can be
seen in Table 4.
Synthesizing the Papers
The final synthesis was based on consensus decisions by the
four authors and was guided by the following three questions:
Which interventions match patients’ views and experiences?,
which interventions have yet to be evaluated in clinical settings?, and does the effect of the intervention seem plausible
from a clinical point of view?
Sample
The search yielded a total of 2,885 papers. This number was
reduced to 358 after sifting the material that potentially met
eligibility criteria on the basis of the title/abstract. After the
full papers were reviewed for relevance/eligibility or for vague
relevance/eligibility, the number of papers was further
reduced to 268. Lastly, the papers were critically appraised
and quality checked, leading to a final number of 59 papers.
Out of these, 48 were quantitative papers and 11 were qualitative papers.
Perspectives in Psychiatric Care 48 (2012) 83–94
© 2011 Wiley Periodicals, Inc.
Mechanical Restraint—Which Interventions Prevent Episodes of Mechanical Restraint?—A Systematic Review
Displaying the Findings
The development of the combined recommendation grading
made it possible to display the registered interventions hierarchically (see Table 5).
The Hierarchy. In Table 5, the first column shows the number
in the hierarchy. The second column shows the description of
the synthesized intervention, and the third column shows the
combined quantitative and qualitative recommendation
grade. The recommendation grade describes the intervention’s ability to exert an effect on reducing the number of
mechanical restraints in the clinical setting, not the degree
of how much it would reduce the number of mechanical
restraints, but if it would. This is described in five levels from 1
to 5, with 1 being the best. 1 indicates an intervention that
most certainly would have an effect on the phenomenon
(mechanical restraint), and 5 indicates a high degree of
uncertainty whether or not the intervention would have an
impact on, or have any relation at all to, the phenomenon.
Combining the quantitative and qualitative recommendations was done by taking the better of the two, to show what
kind of evidence had influence on the combined recommendation; the individual recommendations are shown in brackets, first, the qualitative recommendation grade and, second,
the quantitative recommendation grade.
This is followed by the fourth column showing the effect of
the intervention, where the reduction in the number of
mechanical restraints was divided into five levels from 1 to 5,
with 1 being the best, from 80% to 100% reduction, 2 from
60% to 80%, etc. The effect of the intervention was extrapolated from the quantitative papers and was combined in the
following way:
• No paper: The level was set to 5 (0–20% reduction)
• One paper: The level was transferred directly
• Two or more papers: The level was influenced by:
1. The paper with the best recommendation grade.
2. The paper best describing the intervention.
3. A simple average.
The Matrix. To illustrate which interventions were the most
likely to reduce the use of mechanical restraints, every intervention was placed in a matrix of effect and recommendation
grade (represented as numbers in Figure 1). The closer the
intervention was placed to the upper right corner, the more
likely it could reduce the occurrence of mechanical restraints
(the “better” the intervention was).
Approval and Ethics
Literature reviews do not need approval from the scientific–
ethical committee system (Indenrigs- og SundhedsminisPerspectives in Psychiatric Care 48 (2012) 83–94
© 2011 Wiley Periodicals, Inc.
teriet, 2004). The study followed the Ethical Guidelines for
Nursing Research in the Nordic Countries (Northern Nurse
Federation, 2003) and the White Paper Regarding a Draft Recommendation on Legal Protection of Persons Suffering From
Mental Disorder Especially Those Placed as Involuntary
Patients (Council of Europe, 2000).
Findings
No interventions reached the highest degree of recommendation combined with the highest effect. One intervention
reached the highest effect, with a decrease in mechanical
restraints of 87%, but only with a recommendation grade of 3
(Table 5, no. 1), and another with a recommendation grade of
2, but only with decrease in mechanical restraints of 27%
(Table 5, no. 5).
The Three Highest Ranked Interventions
The highest ranked intervention found was implementation
of cognitive milieu therapy (CMT) (Lykke, Austin, &
Morch, 2008), where the reduction in mechanical restraints
was 87%. CMT was an active, structured, problemorientated, psycho-educational, and dynamic treatment
form. The cognitive treatment model in the environment
gave the patient opportunity to find new alternatives to
inappropriate patterns of reactions and develop new skills
(Oestrich, Lykke, & Holm, 2001). One of the core issues in
the CMT was a schema-focused dialog between the patient
and the nursing staff, in the situation just before a potential
mechanical restraint. Here, the patient had the opportunity
to try out new actions. This sort of patient involvement is
also found elsewhere (Robins, Sauvageot, Cusack, SuffolettaMaierle, & Frueh, 2005; Thyrsting & Hall, 2008) to have
positive influence on the occurrence of mechanical restraint.
Especially one of these papers (Robins et al., 2005) had a
high evidence quality, and for that reason, the combination
of CMT and patient involvement is regarded as the “best”
intervention in this review (Table 5, no. 1).
The second highest ranked intervention is not one particular intervention but programs including several interventions, for instance, patient education, staff education, patient
participation, programmatic changes, high-level administrative endorsement, cultural changes, data analyses, etc. There
are several papers describing different programs (Fisher,
2003; Hellerstein et al., 2007; Khadivi, Patel, Atkinson, &
Levine, 2004; Sullivan et al., 2005; Taxis, 2002). An average of
these gives a 76% decrease of mechanical restraints (Table 5,
no. 2). The evidence consisted mostly of “before- and after”
papers, and because some of these are well founded, the recommendation grade is the same as in no. 1.
The third highest ranked intervention is implementation
of patient-centered care (Fletcher & Stevenson, 2001; Robins
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Mechanical Restraint—Which Interventions Prevent Episodes of Mechanical Restraint?—A Systematic Review
Table 5. Intervention Hierarchy
No.
Intervention
Recommendation
Effect
Literature Reference
Implementation of cognitive milieu therapy reduces the number
of mechanical restraint episodes, among other things, through
patient involvement and empowerment.
Combined intervention programs are effective in avoiding
mechanical restraints, for example, patient participation,
patient education, staff education, programmatic changes,
high-level administrative endorsement, cultural changes, data
analysis, etc.
Implementation of patient-centered care with a higher degree of
patients’ positive involvement in their own care reduces the
number of mechanical restraint episodes.
The identification of the patients’ crisis triggers unique calming
techniques and decisions on specific crisis interventions early in
the admission procedure, thereby reducing the number of
mechanical restraints.
Introduction of validated risk assessment systems including
suggestions of care interventions reduces the number of
mechanical restraints.
Effective treatment of substance abuse and psychosis reduce the
number of mechanical restraint episodes; the treatment of
mental illnesses is also described elsewhere in the review.
Mandatory review from qualified clinical experts, for example, as
post-incident review, minimizes the number of mechanical
restraint episodes.
Better staff training reduces the number of mechanical restraints
(longer duration of the training, more staff participating, use of
different and involving education methods, higher quality of
the content, and greater diversity of the topics, for example,
legislation, crisis management, physical intervention strategies,
antecedents, warning signs, de-escalation techniques, etc.).
Staff attitudes such as positive care for the patients, respect,
collaboration, communication, humanism, empathy, and less
control and involuntary procedures reduce the number of
mechanical restraints.
3 (3–4)
1
Lykke et al., 2008; Robins et al., 2005; Thyrsting and Hall, 2008
3 (n.a.–3)
2
Fisher, 2003; Hellerstein et al., 2007; Khadivi et al., 2004; Sullivan
et al., 2005; Taxis, 2002
3 (3–4)
2
Fletcher and Stevenson, 2001; Robins et al., 2005; Sullivan et al.,
2004; Thyrsting and Hall, 2008
3 (4–3)
3
Jonikas, Cook, Rosen, Laris, and Kim, 2004; McCain and
Kornegay, 2005; Meehan, Mcintosh, and Bergen, 2006; Wynn
and Mykleburst, 2006
2 (n.a.–2)
4
Abderhalden et al., 2008; Cochrane-Brink, Lofchy, and
Sakinofsky, 2000; Dernevik, Grann, and Johansson, 2002
4 (n.a.–4)
3
Fletcher and Stevenson, 2001; Palmstierna and Olsson, 2007;
Sullivan et al., 2004; Thyrsting and Hall, 2008
4 (n.a.–4)
3
Donat, 1998; Prescott, Madden, Dennis, Tisher, and Wingate,
2007
3 (3–4)
4
4 (4–4)
4
10
Higher patient–staff ratio reduces the number of mechanical
restraints.
4 (n.a.–4)
4
Bonner, Lowe, Rawcliffe, and Wellman, 2002; Bowers, Nijman,
et al., 2006; Cardell and Pitula, 1999; Delaney and Johnson,
2006; Hahn, Abderhalden, Duxbury, Halfens, and Needham,
2006; Jonikas et al., 2004; Lee et al., 2001; Mackay, Paterson,
and Cassells, 2005; Needham, Dassen, Halfens, Haug, and
Fisher, 2005; Spokes et al., 2002; Wright et al., 2005
Allen, Carpenter, Sheets, Miccio, and Ross, 2003; Bowers,
Alexander, Simpson, Ryan, and Carr-Walker, 2007; Bowers,
Brennan, Flood, Lipang, and Oladapo, 2006; Duxbury, 2002;
Gillig, Markert, Barron, and Coleman, 1998; Meehan et al.,
2006; Robins et al., 2005; Spokes et al., 2002
Smith et al., 2005; Wynn, 2003
11
The higher educated the staff, the fewer episodes of mechanical
restraints.
3 (3–4)
5
12
The more experienced the staff, the fewer episodes of
mechanical restraints.
3 (3–4)
5
13
If nurses change their focus from considering the patient as
deviant to being a resource in his/her own treatment, it would
decrease the number of mechanical restraint.
Early and adequate administration of oral p.n. medication guided
by the individual patients’ problems, medication experiences,
and preferences leads to fewer mechanical restraint episodes.
Debriefing, defusing, and crisis intervention minimize the number
of mechanical restraint episodes.
Patients’ response to rules can be positive and lead to fewer cases
of mechanical restraint, for instance, if staff helps patients to
understand not only the rules, but also the rationale for the
presence of such rules. If the staff manages to make patients
understand that the rules are imposed out of concern for their
welfare, then patients may be less reluctant to following these
rules.
Activity-based nursing interventions, for example, physical
activities, are effective in avoiding mechanical restraints.
3 (3–n.a.)
5
4 (4–4)
5
4 (5–4)
5
4 (5–4)
5
4 (5–4)
5
1
2
3
4
5
6
7
8
9
14
15
16
17
88
Bonner et al., 2002; Cardell and Pitula, 1999; Delaney and
Johnson, 2006; Flannery, Stone, Rego, Walker, and Farley,
2006; Gim et al., 1999; Mackay et al., 2005; Spokes et al.,
2002
Bonner et al., 2002; Bowers, Jeffery, et al., 2007; Cardell and
Pitula, 1999; Delaney and Johnson, 2006; Flannery et al.,
2006; Janssen, Noorthoorn, Linge, and Lendemeijer, 2007;
Mackay et al., 2005; Spokes et al., 2002
Vatne and Fagermoen, 2007
Allen et al., 2003; Goedhard, Stolker, Nijman, Egberts, and
Heerdink, 2007; McCain and Kornegay, 2005; Meehan et al.,
2006; Thapa et al., 2003
Bonner et al., 2002; Bowers, Simpson, et al., 2006; Flannery
et al., 2006; Jonikas et al., 2004
Alexander, 2006; Duxbury, 2002; Gillig et al., 1998; Meehan
et al., 2006; Robins et al., 2005
Meehan et al., 2006; Thomas, Jones, Johns, and Trauer, 2006
Perspectives in Psychiatric Care 48 (2012) 83–94
© 2011 Wiley Periodicals, Inc.
Mechanical Restraint—Which Interventions Prevent Episodes of Mechanical Restraint?—A Systematic Review
Table 5. Continued
No.
Intervention
Recommendation
Effect
Literature Reference
18
Several mental and physical working environmental factors
influence positively the number of mechanical restraints, for
example, good management as a high degree of order,
organization, or support; adequate staffing; psychiatric
training; rotation; education; no crowding; emergency backup,
etc. Several of these factors are described elsewhere in the
review.
Less crowding, for example, less stimuli and less environmental
stress, and more personal space decrease the number of
mechanical restraints.
Higher regular staff and lower substitute ratio reduce the number
of mechanical restraints.
4 (5–4)
5
Bonner et al., 2002; Bowers, Allan, Simpson, Jones, and
Whittington, 2008; Daffern, Mayer, and Martin, 2006; Owen,
Tarantello, Jones, and Tennant, 1998; Whittington and
McLaughlin, 2000
4 (5–4)
5
Meehan et al., 2006; Vaaler, Morken, Fløvig, Iversen, and Linaker,
2006
4 (5–4)
5
4 (n.a.–4)
5
Bonner et al., 2002; Bowers, Allan, Simpson, Nijman, and
Warren, 2007; Spokes et al., 2002
Lind, Kaltiala-Heino, Suominen, Leino-Kilpi, and Valimaki, 2004;
Van Doeselaar, Sleegers, and Hutschemaekers, 2008
4 (n.a.–4)
5
D’Orio, Purselle, Stevens, and Garlow, 2004
4 (n.a.–4)
5
Wynn, 2003
4 (n.a.–4)
5
Duxbury and Whittington, 2005
4 (n.a.–4)
5
Vaaler, Morken, and Linaker, 2005
4 (n.a.–4)
5
Janelli and Kanski, 1998
5 (5–n.a.)
5
Meehan et al., 2006
19
20
21
22
23
24
25
26
27
Staffs’ opposition toward mechanical restraint because of the
perception that mechanical restraint is ethically problematic
decreases the number of mechanical restraints.
Alarm systems, for example, video surveillance and radio systems,
and well-trained response teams reduce the number of
mechanical restraints.
Better care alliance between patients and the nursing staff
reduces the number of mechanical restraints.
Communication especially communicative de-escalation reduces
the number of mechanical restraint episodes.
Well-maintained and familiar surroundings reduce the number of
mechanical restraints.
Music as diversion and relaxation before and after mechanical
restraint reduces the number of mechanical restraint episodes.
Separation of acutely disturbed patients reduces the number of
mechanical restraint episodes.
No. refers to the number in the hierarchy where 1 is highest/best. Recommendation describes the whole body of evidence regarding a specific intervention level of scientific
“truth” or its potential for clinical application. To show what kind of evidence that mostly influenced the combined recommendation, the individual recommendations are
shown in brackets, first, the qualitative recommendation grade and, second, the quantitative recommendation grade. All from 1 to 5, where 1 is the highest/best. n.a. referred
to no available paper. Effect refers to the reduction in the number of mechanical restraints, from 1 to 5, with 1 being the best, from 80% to 100% reduction, 2 from 60% to
80%, etc.
p.n., pro necessitate (as needed).
et al., 2005; Sullivan, Wallis, & Lloyd, 2004; Thyrsting & Hall,
2008) (Table 4, no. 3). Here, implementation of the Tidal
Model (TM) reduces the number of mechanical restraints by
68%. TM is a philosophical approach to the discovery of
mental health. TM focuses on helping people who have experienced some metaphorical “breakdown” to recover their lives
as fully as possible, by reclaiming the personal story of their
distress and difficulty (Barker & Buchanan-Barker, 2010).
One of the core elements in TM is empowerment of the
patient. Empowerment is only possible if the patients are
involved in their own care. Patient involvement is also found
elsewhere (Robins et al., 2005; Thyrsting & Hall, 2008) to have
a positive influence on the occurrence of mechanical
restraint. Therefore, the recommendation grade is the same as
in the first intervention described.
Discussion
The highest ranked intervention was CMT combined with
patient involvement. To our knowledge, this result has not
Perspectives in Psychiatric Care 48 (2012) 83–94
© 2011 Wiley Periodicals, Inc.
Figure 1. Effect and Recommendation Grade Matrix
The numbers in the matrix refer to a specific intervention (the first
number in the intervention hierarchy [Table 5]).
89
Mechanical Restraint—Which Interventions Prevent Episodes of Mechanical Restraint?—A Systematic Review
been identified in prior reviews, one probable cause being
that the CMT paper was not published in English, and in the
abstract, the effect was only described as a significant effect,
not the exact figure of a staggering 87% reduction. Also, the
fact that this paper is rather new (from 2008) might explain its
limited impact.
The second highest ranked intervention was combined
interventions (many interventions in a program or a
package). This finding is supported by an earlier review
(Gaskin, Elsom, & Happell, 2007) where the authors’ conclusion recommended a combination of several interventions to
reduce the number of mechanical restraints.
The third highest ranked intervention was implementation
of patient-centered care, which means that the patient is
placed in the center of his/her own care. Despite being in
closed units where restrictions to individual liberty often
must be exerted, the patient should be given as much influence over his/her situation as possible. The positive influence
on mechanical restraint by patient-centered or patientinvolving care is also supported in other reviews (Gaskin
et al., 2007; Sailas & Wahlbeck, 2005).
No interventions reached the highest degree of recommendation combined with the highest effect, and to create strong
evidence-based practice in this area, substantially further
research is needed. This is necessary because implementing
not effective interventions could be both expensive and
unethical.
Many apparently different interventions centered on the
patient could be more efficacious on reducing the number of
mechanical restraints. This point could lead us to speculate
that therapeutic interventions could allow us to reduce coercive measures in psychiatry.
Limitations
First, only one person was involved in the initial review
process, until the drawing up of evidence statements; it might
be argued that two or more persons reading all the material
followed by consensus evaluations would produce more reliable results. However, all the evidence was rated in exactly the
same way (no inter-rater differences).
Second, the quantification combining qualitative and
quantitative evidence is new and possibly controversial. A
simple argument in favor is that the more mechanical
restraint and a specific intervention are interrelated (no
matter if this relation in nature is quantitative or qualitative),
the greater the evidence for this relation becomes. So, in the
authors’ opinion, as mechanical restraint is a multifaceted
phenomenon and the evidence is limited, it is reasonable to
combine well-established quantitative review procedures
with well-established quantified qualitative review procedures in order to deduce maximum information from the
available papers.
90
Implication for Research
There is an obvious lack of high-quality intervention studies,
which may be because of the vast difficulties in performing
such studies because of the complexity of the phenomenon
and because of the fact that the interventions must be performed in clinical settings. The findings of this review point to
the need for randomized clinical trials on specific interventions. The likelihood of implementing interventions in
several units as a cluster-randomized trial would constitute a
suitable study design for this purpose. Before choosing the
intervention for the clinical trial, it could be interesting to
investigate the “effect and recommendation grade matrix”
through a cross-sectional study evaluating the potency of the
individual interventions in relation to mechanical restraints
in terms of hypotheses testing and falsification. This would
strengthen the choice of intervention.
Implications for Nursing Practice
The papers included in this review do not imply that the interventions easily can be transferred to practice because in many
cases, they describe specific settings and narrow populations.
Neither did any of the interventions reach the highest degree
of recommendation, as far as influencing the number of
mechanical restraints in the clinical setting is concerned.
However, no intervention seemed to have any negative or
harmful side effects. Considering that mechanical restraint is
one of the most intrusive care interventions, every effort to
avoid it must be used until convincing evidence is provided.
Acknowledgments
For funding this project, we thank: the Mental Health Centre
Sct. Hans, Copenhagen University Hospital, the mental
health services in the capital region of Denmark, and the
Research Foundation in the capital region of Denmark.
The authors wish to thank Margit Asser (Deputy Head of
Centre, Mental Health Centre Sct. Hans, Roskilde, Denmark),
Jeanett Bauer (Employed Senior Physician, Psychiatric Centre
Copenhagen, Bispebjerg Hospital, Denmark), and Thomas
Werge (Head of Research, Mental Health Centre Sct. Hans,
Roskilde, Denmark) for valuable comments and careful
reading during the writing process.
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Perspectives in Psychiatric Care
Corrigendum
ppc_337
ISSN 0031-5990
183..184
Bak, J., Brandt-Christensen, M., Sestoft, D. M., & Zoffmann, V. (2011). Mechanical restraint—Which interventions prevent episodes of mechanical restraint?—A systematic review. Perspectives in Psychiatric Care, 48(2), 83–94.
Under “Findings” and sub-heading “The Three Highest Ranked Interventions”:
1. The citations for “Robins, Sauvageot, Cusack, Suffoletta-Maierle, & Frueh, 2005” and “(Robins et al., 2005)” should be
removed.
2. The following two sentences have been changed.
“The study included papers published after 1998.”
The correct statement is:
“The study included papers published from 1998.”
And,
“Especially one of these papers (Robins et al., 2005) had a high evidence quality, and for that reason, the combination of CMT
and patient involvement is regarded as the ‘best’ intervention in this review (Table 5, no. 1).”
The correct statement is:
“Especially this paper had a high evidence quality and for that reason, the combination of CMT and patient involvement is
regarded as the ‘best’ intervention in this review (Table 5, no. 1).”
3. Several references have been amended in Table 5. The corrected Table 5 is below:
Table 5. Intervention Hierarchy
No.
1
2
3
4
5
6
7
8
Intervention
Recommendation
Effect
Literature Reference
Implementation of cognitive milieu therapy reduces the number
of mechanical restraint episodes, among other things, through
patient involvement and empowerment.
Combined intervention programs are effective in avoiding
mechanical restraints, for example, patient participation,
patient education, staff education, programmatic changes,
high-level administrative endorsement, cultural changes, data
analysis, etc.
Implementation of patient-centered care with a higher degree of
patients’ positive involvement in their own care reduces the
number of mechanical restraint episodes.
The identification of the patients’ crisis triggers unique calming
techniques and decisions on specific crisis interventions early in
the admission procedure, thereby reducing the number of
mechanical restraints.
Introduction of validated risk assessment systems including
suggestions of care interventions reduces the number of
mechanical restraints.
Effective treatment of substance abuse and psychosis reduce the
number of mechanical restraint episodes; the treatment of
mental illnesses is also described elsewhere in the review.
Mandatory review from qualified clinical experts, for example, as
post-incident review, minimizes the number of mechanical
restraint episodes.
Better staff training reduces the number of mechanical restraints
(longer duration of the training, more staff participating, use of
different and involving education methods, higher quality of
the content, and greater diversity of the topics, for example,
legislation, crisis management, physical intervention strategies,
antecedents, warning signs, de-escalation techniques, etc.).
3 (3–4)
1
Lykke et al., 2008; Thyrsting and Hall, 2008
3 (n.a.–3)
2
Fisher, 2003; Hellerstein et al., 2007; Khadivi et al., 2004; Sullivan
et al., 2005; Taxis, 2002
3 (3–4)
2
Fletcher and Stevenson, 2001; Sullivan et al., 2004; Thyrsting and
Hall, 2008
3 (4–3)
3
Jonikas, Cook, Rosen, Laris, and Kim, 2004; McCain and
Kornegay, 2005; Meehan, Mcintosh, and Bergen, 2006; Wynn
and Mykleburst, 2006
2 (n.a.–2)
4
Abderhalden et al., 2008; Cochrane-Brink, Lofchy, and
Sakinofsky, 2000; Dernevik, Grann, and Johansson, 2002
4 (n.a.–4)
3
Fletcher and Stevenson, 2001; Palmstierna and Olsson, 2007;
Sullivan et al., 2004; Thyrsting and Hall, 2008
4 (n.a.–4)
3
Donat, 1998; Prescott, Madden, Dennis, Tisher, and Wingate,
2007
3 (3–4)
4
Bonner, Lowe, Rawcliffe, and Wellman, 2002; Bowers, Nijman,
et al., 2006; Delaney and Johnson, 2006; Hahn, Abderhalden,
Duxbury, Halfens, and Needham, 2006; Jonikas et al., 2004;
Lee et al., 2001; Mackay, Paterson, and Cassells, 2005;
Needham, Dassen, Halfens, Haug, and Fisher, 2005; Spokes
et al., 2002; Wright et al., 2005
doi:10.1111/j.1744-6163.2012.00337.x
Perspectives in Psychiatric Care 48 (2012) 183–184
© 2012 Wiley Periodicals, Inc.
183
Corrigendum
Table 5. Continued
No. Intervention
Recommendation Effect Literature Reference
Staff attitudes such as positive care for the patients, respect,
collaboration, communication, humanism, empathy, and less
control and involuntary procedures reduce the number of
mechanical restraints.
4 (4–4)
4
Allen, Carpenter, Sheets, Miccio, and Ross, 2003; Bowers, Alexander,
Simpson, Ryan, and Carr-Walker, 2007; Bowers, Brennan, Flood,
Lipang, and Oladapo, 2006; Cardell and Pitula, 1999; Duxbury,
2002; Gillig, Markert, Barron, and Coleman, 1998; Meehan et al.,
2006; Robins et al., 2005; Spokes et al., 2002
10
Higher patient–staff ratio reduces the number of mechanical
restraints.
4 (n.a.–4)
4
Smith et al., 2005; Wynn, 2003
11
The higher educated the staff, the fewer episodes of mechanical
restraints.
3 (3–4)
5
Delaney and Johnson, 2006; Flannery, Stone, Rego, Walker, and
Farley, 2006; Gim et al., 1999; Mackay et al., 2005; Spokes et al.,
2002
12
The more experienced the staff, the fewer episodes of mechanical
restraints.
3 (3–4)
5
13
If nurses change their focus from considering the patient as
deviant to being a resource in his/her own treatment, it would
decrease the number of mechanical restraint.
3 (3–n.a.)
5
Bowers, Jeffery, et al., 2007; Delaney and Johnson, 2006;
Flannery et al., 2006; Janssen, Noorthoorn, Linge, and
Lendemeijer, 2007; Mackay et al., 2005; Spokes et al., 2002
Vatne and Fagermoen, 2007
14
Early and adequate administration of oral p.n. medication guided
by the individual patients’ problems, medication experiences,
and preferences leads to fewer mechanical restraint episodes.
4 (4–4)
5
Allen et al., 2003; Goedhard, Stolker, Nijman, Egberts, and
Heerdink, 2007; McCain and Kornegay, 2005; Meehan et al.,
2006; Thapa et al., 2003
15
Debriefing, defusing, and crisis intervention minimize the number
of mechanical restraint episodes.
Patients’ response to rules can be positive and lead to fewer cases
of mechanical restraint, for instance, if staff helps patients to
understand not only the rules, but also the rationale for the
presence of such rules. If the staff manages to make patients
understand that the rules are imposed out of concern for their
welfare, then patients may be less reluctant to following these
rules.
Activity-based nursing interventions, for example, physical
activities, are effective in avoiding mechanical restraints.
Several mental and physical working environmental factors
influence positively the number of mechanical restraints, for
example, good management as a high degree of order,
organization, or support; adequate staffing; psychiatric training;
rotation; education; no crowding; emergency backup, etc.
Several of these factors are described elsewhere in the review.
Less crowding, for example, less stimuli and less environmental
stress, and more personal space decrease the number of
mechanical restraints.
Higher regular staff and lower substitute ratio reduce the number
of mechanical restraints.
Staffs’ opposition toward mechanical restraint because of the
perception that mechanical restraint is ethically problematic
decreases the number of mechanical restraints.
Alarm systems, for example, video surveillance and radio systems,
and well-trained response teams reduce the number of
mechanical restraints.
Better care alliance between patients and the nursing staff reduces
the number of mechanical restraints.
Communication especially communicative de-escalation reduces
the number of mechanical restraint episodes.
Well-maintained and familiar surroundings reduce the number of
mechanical restraints.
Music as diversion and relaxation before and after mechanical
restraint reduces the number of mechanical restraint episodes.
Separation of acutely disturbed patients reduces the number of
mechanical restraint episodes.
4 (5–4)
5
4 (5–4)
5
Bonner et al., 2002; Bowers, Simpson, et al., 2006; Flannery
et al., 2006; Jonikas et al., 2004
Alexander, 2006; Duxbury, 2002; Gillig et al., 1998; Meehan
et al., 2006; Robins et al., 2005
4 (5–4)
5
Meehan et al., 2006; Thomas, Jones, Johns, and Trauer, 2006
4 (5–4)
5
Bonner et al., 2002; Bowers, Allan, Simpson, Jones, and
Whittington, 2008; Daffern, Mayer, and Martin, 2006; Owen,
Tarantello, Jones, and Tennant, 1998; Whittington and
McLaughlin, 2000
4 (5–4)
5
Meehan et al., 2006; Vaaler, Morken, Fløvig, Iversen, and Linaker,
2006
4 (5–4)
5
4 (n.a.–4)
5
Bonner et al., 2002; Bowers, Allan, Simpson, Nijman, and
Warren, 2007; Spokes et al., 2002
Lind, Kaltiala-Heino, Suominen, Leino-Kilpi, and Valimaki, 2004;
Van Doeselaar, Sleegers, and Hutschemaekers, 2008
4 (n.a.–4)
5
D’Orio, Purselle, Stevens, and Garlow, 2004
4 (n.a.–4)
5
Wynn, 2003
4 (n.a.–4)
5
Duxbury and Whittington, 2005
4 (n.a.–4)
5
Vaaler, Morken, and Linaker, 2005
4 (n.a.–4)
5
Janelli and Kanski, 1998
5 (5–n.a.)
5
Meehan et al., 2006
9
16
17
18
19
20
21
22
23
24
25
26
27
No. refers to the number in the hierarchy where 1 is highest/best. Recommendation describes the whole body of evidence regarding a specific intervention level of scientific “truth” or its potential for clinical application. To show what kind of evidence that mostly influenced the combined recommendation, the individual recommendations are shown in brackets, first, the qualitative recommendation grade and, second, the quantitative recommendation
grade. All from 1 to 5, where 1 is the highest/best. n.a. referred to no available paper. Effect refers to the reduction in the number of mechanical
restraints, from 1 to 5, with 1 being the best, from 80% to 100% reduction, 2 from 60% to 80%, etc.
p.n., pro necessitate (as needed).
184
Perspectives in Psychiatric Care 48 (2012) 183–184
© 2012 Wiley Periodicals, Inc.
Paper 2
Coercion within Danish psychiatry
compared with 10 other European countries.
Coercion within Danish psychiatry compared
with 10 other European countries
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JESPER BAK, HELLE AGGERNÆS
Bak J, Aggernæs H. Coercion within Danish psychiatry compared with 10 other European
countries. Nord J Psychiatry 2012;66:297–302.
Background: In 2008, the European Committee for the Prevention of Torture and Inhuman
or Degrading Treatment or Punishment (CPT) criticized the use of mechanical restraint in
Denmark and referred to it as ill-treatment. What do other European countries do better? To
answer this question, we compared the use of coercive measures regarding psychiatric inpatients
in Denmark and comparable European countries. Aims: Comparing coercive measures from
Denmark, Sweden, Norway, Finland, Iceland, Belgium, The Netherlands, United Kingdom,
Ireland, France and Italy. Methods: Review of international literature and a cross-sectional study
performed as a questionnaire survey. Results: Denmark used more mechanical restraint and
holding than Finland and Norway; however Sweden used twice as much as Denmark. Finland
used more seclusion than did the other countries. Norway was the country that used the
smallest amount of physical coercion. Only Norway, Finland, Sweden and Denmark had
comparable representative data on coercion. Conclusions: Norway used less physical restraint
than Denmark. We could not find any obvious reasons for the differences in the use of physical
restraint. Clinical implications: Comparing the factors surrounding coercion between countries
may serve as a basis for minimizing coercion and carrying it out in the most acceptable manner
for the patients, thereby providing better psychiatric treatment in Europe.
• Coercion, Mental health, Psychiatric code, Restraint.
Jesper Bak, Head Nurse, R.N., S.D., M.P.H., Ph.D. student, Mental Health Centre Sct. Hans,
Boserupvej 2, 4000 Roskilde, Denmark, E-mail: [email protected]; Accepted 12 October 2011.
I
n the autumn of 2008, public interest on coercion was
rekindled following the European Committee for the
Prevention of Torture and Inhumane or Degrading Treatment or Punishment’s visit to Denmark. The Committee
criticized the use of mechanical restraint in terms of
duration and frequency and labelled it ill-treatment.
Before changing the psychiatric legislation in Denmark,
the Minister of Health requested that a comparison
between Denmark and comparable European countries
were made on the use of coercive measures targeted at
psychiatric inpatients together with a professional expert
evaluation on the coercive measures already used in
Denmark.
The National Board of Health appointed the authors
to help prepare a clearing report (1). The report was
modified according to discussions in an appointed group
of non-governmental organizations, academics and professionals prior to publication.
Aim
To compare the use of coercive measures on psychiatric
inpatients between Denmark (DK) and Sweden (SE),
© 2012 Informa Healthcare
Norway (NO), Finland (FI), Iceland (IC), Belgium (BE),
The Netherlands (NL), United Kingdom (UK), Ireland
(IE), France (FR) and Italy (IT), in order to share
knowledge and learn about what other countries do to
minimize coercion.
Material and methods
Data were collected by:
1)
Reviewing international reports, research literature
and national registers;
2) Performing a survey, asking government officials and
medical specialists to complete a questionnaire.
Literature review
The review covered legislation and coercive measures
used in psychiatry across Europe comprising: forced
medication/long period, forced medication/short period
(in some papers defined acute medication), mechanical
restraint, seclusion/isolation, physical restraint/holding,
time out and constant observation.
DOI: 10.3109/08039488.2011.632645
J BAK & H AGGERNÆS
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The coercive measures were mostly defined as suggested by Bowers et al. (2).
The review was conducted between April and June
2009, with an update in March 2010, and covered the
years from 1999 to 2010.
The searches included literature in the languages:
English, Danish, Norwegian, Dutch, Finnish and Swedish.
The search strategy was structured:
1) An overall search for legislation and coercion across
selected databases;
2) A search to identify registers and reports, e.g. governmental reports not indexed in the major databases;
3) A topic-specific search on PubMed;
4) Reference lists of the most relevant papers were
checked for articles not otherwise found.
Major differences between countries were found in
almost every area under investigation:
•
•
•
•
•
•
•
Number of psychiatric beds per 100,000 inhabitants:
from 8 in IT to 152 in BE.
Number of forced admissions per 100,000 inhabitants:
from 31 in IT to 218 in FI.
Mean length of stay in days: from 14 days in IT to
52 days in UK.
Number of forensic psychiatric beds per 100,000
inhabitants: from 0 in NO to 10.3 in BE.
Number of psychiatric beds in jails per 100,000
inhabitants: from 0 in several countries to 4.6 in NL.
Year of last revision of the psychiatric code; from
1990 in FR to 2009 in NL.
National register for coercion: four countries had
national registers and seven countries had none.
Number of psychiatrists per 100,000 inhabitants: from
7 in IE to 26 in FI.
Number of nurses working in Mental Health Care:
from 33 in IT to 163 in FI.
All references were placed in an electronic referencemanaging program (Ref. Man 11).
Once the references were retrieved, the following sifting process was initiated:
•
• First sift—sift for material that potentially met eligibility criteria based on title/abstract.
• Second sift—full reference that appeared relevant and
eligible or where relevance/eligibility was not clear
from the abstract where scrutinized.
• Third sift—lastly, the references were critically
assessed.
No formal statistics were performed because of the low
number of respondents.
•
The different use of coercive measures
A questionnaire was developed and covered the same
areas as mentioned earlier in the literature review.
The questionnaires were sent to governmental health
authorities (European Platform of Supervisory Organisations, EPSO) and the Psychiatric Section of the European
Union of Medical Specialists (Union Européenne des
médicins Spécialistes, UEMS). An example from the
questionnaire appears in Supplementary Appendix 2 to
be found online at http://informahealthcare.com/doi/abs/
10.3109/08039488.2011.632645.
The questionnaire survey was conducted between May
and July 2009.
Table 2 shows the different types of coercive measures
that can be applied in the countries, as reported in the
questionnaire survey (2009) where specialists from EPSO
and UEMS have described the legislation and clinical use
of the coercive measures in their countries.
As shown in Table 2, all countries allowed the use of
forced medication in some form in 2009. In NL and FR,
only acute medication was allowed. UK was the only
country where mechanical restraint was not allowed and
DK was the only country where seclusion was not
allowed.
Physical restraint/holding was used in two different
ways: for a short period e.g. while the patient was
restrained either during forced medication or for longer
periods to calm the patient. Some countries argue that
holding a patient for a longer period, especially very a
psychotic patient, was more intrusive to the patient than
mechanical restraint and seclusion.
Time out and constant observation were evaluated
differently between countries. Some saw it as coercion,
others as “best practice”.
Results
The number of physically coercive measures
per 100,000 inhabitants
The focused search strategy is shown in Supplementary
Appendix 1 to be found online at http://informahealthcare.
com/doi/abs/10.3109/08039488.2011.632645.
Questionnaire survey
Background data
The background data in Table 1 were collected from several
sources: national registers, governmental and specialist
reports, research papers and the questionnaire survey
(3–11).
298
Table 3 shows the numbers of the three most frequent
physical coercive measures: mechanical restraint, seclusion and holding. The numbers were obtained from
national registers (DK, NO, FI, NL), national reports
(SE) and scientific papers (UK, IT) (12–19).
NORD J PSYCHIATRY·VOL 66 NO 5·2012
COERCION IN EUROPE
Table 1. Background data.
DK
SE
NO
FI
IS
BE
NL
UK
IE
FR
IT
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Psychiatric beds per 100,000 inhabitants (3) (2007)
61
54 119
72 n.a. 152 114
23
94
95
8
Number of forced admissions per 100,000 inhabitants (4–7) (1999–2001)
70 114 135 218 n.a.
47
44
93
74 103 31
Mean length of stay in days (3, 8) (1998 and 2007)
30
25
29
38 n.a.
25 n.a.
52
16
36 14
Forensic psychiatric beds per 100,000 inhabitants (9, 10) (2002–2007)
6.6
8.0
0
6.9 2.3 10.3
9.8
6.1 2.2
0.8 2.2
Psychiatric beds in jails per 100,000 inhabitants (9, 10) (2002–2007)
0
1.6
0
1.2
0
2.1
4.6
0
0
1.2 n.a.
Year of last revision of the psychiatric code (Survey, 2009)
2006 2008 2006 2001 n.a. 2007 2009 2007 2001 1990 n.a.
National register for coercion (Survey, 2009)
X (X)
X
X
X
Psychiatrists per 100,000 inhabitants (3) (2007)
11
24
16
26 n.a.
23
15
13
7
22 10
Nurses working in Mental Health Care per 100,000 inhabitants (3, 11) (2007)
64
73 n.a. 163 n.a. n.a. 122
52 126 n.a. 33
n.a.: No available information.
Year: The available data were recorded from 1998 to 2008. The numbers of forced admissions: DK: 2000, SE: 1998, NO: 2001, FI: 2000, BE: 1998,
NL: 1999, UK: 1998, IE: 1999, FR: 1999, IT: 2001. Mean length of stay was from 2007 only NO.UK and FR were from 1998.
Mean length of stay: The median number of days in mental hospitals and community-based psychiatric inpatient units.
DK: The number of forced admissions includes forced compulsory retention of voluntarily admitted patients; the number on forced admissions alone
would be 34. “Nurses working in Mental Health Care” refers to all nurses in the number of specialized nurses that was 9 (3, 11). The length of stay is
only from community-based psychiatric inpatient units.
SE: National register for coercion should start in 2009. The length of stay was only from community-based psychiatric inpatient units.
NO: The number of forced admissions is from 2001.
FI: The length of stay is only from mental hospitals.
IS: IS did not have a Psychiatric code, but a § in the law regarding guardianship “Lögræðislögin” from 1997.
BE: The number of beds included some ambulatory inpatients.
UK: The number of psychiatric beds does not include Scotland. The number of forced admissions includes forced compulsory retention of voluntarily
admitted patients; the number of forced admissions alone would be 48. The mean length of stay includes forensic patients. The last version of the
approved mental health legislation in Scotland was before 2005.
FR: The number of forced admissions was adjusted according to Barbato’s comments.
IT: The number of beds only represented Sardinia. The number of forced admissions only represented the Lombardia region, but numbers from whole
IT in 1997 was 26 and quite similar. IT had psychiatric beds in jails; however, the number of beds was uncertain. The length of stay was only from
community-based psychiatric inpatient units. Year of last revision of the psychiatric code was uncertain, we only know that it was after 2005 (3).
Table 2. Applied methods of coercion.
Forced medication/long period
Forced medication/short period
Mechanical restraint
Seclusion/isolation
Physical restraint/holding
Time out
Constant observation
Are other types of coercion used
DK
SE
NO
FI
IS
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
BE
NL
X
X
X
X
X
X
X
X
X
X
X
X
UK
IE
X
X
X
X
X
X
X
X
X
X
X
X
FR
IT
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
DK: If patients complained about the use of forced medication, it would give 2–3 weeks delayed effect before medication could be initiated. During
mechanical restraint, constant observation was required. Seclusion had only been allowed since 2005 and only in a particularly high security department
for extraordinarily dangerous psychiatric patients. Physical restraint was only used few minutes in connection with other coercive measures. Constant
observation as a coercive measure was first reported if it was prolonged more than 24 h.
SE: Seclusion was only used if the patient was quite dangerous for other patients. Time out was regarded as isolation (Time out was defined as being
placed in a room with the door unlocked).
NO: Seclusion was only allowed in acute situations and was not to be used if patients were under 16 years. Time out was not regarded as coercion.
Constant observation was first regarded as a coercive measure after 12–24 h.
FI: During mechanical restraint, constant observation was required if patients were under 18 years. During seclusion, constant observation was required
if patients were under 18 years. Physical restraint was rarely used in adult psychiatry and could only be used in child psychiatry if parents agreed.
IS: Mechanical restraint has not been used as a routine measure for decades. Physical restraint was only used a few minutes in connection with forced
medication and to calm patients. Constant observation was not regarded as coercion.
BE: Beside three-point restraint (waist, hand and foot), chest belts and straitjackets were allowed. During mechanical restraint and seclusion, the staff
could use camera surveillance and should always be able to hear the patient. Time out was only allowed max 48 h.
NL: Today, mechanical restraint is rarely used in acute psychiatric wards. The use in chronic wards was unknown.
UK: The forced medication was only allowed if it was part of the total treatment plan. Seclusion was only allowed in acute situations.
FR: Seclusion was described in a clinical guideline. If seclusion was prolonged more than 24 h, the patient was transferred to a special unit (Unites pour
maladies difficiles). Physical restraint was used in relation to forced medication and acute situations to calm patients and to prevent seclusion.
NORD J PSYCHIATRY·VOL 66 NO 5·2012
299
J BAK & H AGGERNÆS
Table 3. Physical coercion/100,000 inhabitants.
DK SE NO FI IS BE NL UK IE FR IT
Table 4. Ranking of coercive measures with respect to perceived
intrusion.
DK SE NO FI IS BE NL UK IE FR IT
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Mechanical restraint 34 70 21 20 n.a. n.a. 14 0 n.a. n.a. 7
Seclusion/isolation
0 31 2 43 n.a. n.a. 34 4 n.a. n.a. n.a.
Physical restraint/
18 0 6 8 n.a. n.a. n.a. 13 n.a. n.a. 7
holding
n.a.: Not available.
DK: 2007. The numbers included geronto-, child/adolescence and forensic
psychiatry (12). In DK, it was possible for the patients to be subjected to
voluntary mechanical restraint, which happened in 10% of all incidents.
NO: 2007. The numbers included geronto-, adolescence and forensic
psychiatry (13).
FI: 2007. The numbers included geronto-, adolescence and forensic
psychiatry (14).
SE: 2007. The numbers came from control visits in the southern hospital
region made by the National Board of Health and Welfare. The numbers
were then extrapolated to the whole of SE. The numbers included geronto-,
adolescence and forensic psychiatry (15, 16).
NL: 2006. The numbers came from the Dutch hospital database (IGZ) (17).
Mechanical restraint was only used for protection in geronto-psychiatry.
UK: 2002. The numbers came from three hospitals in London. The numbers
were then extrapolated to the whole of the UK. The numbers did not
include geronto-, adolescence and forensic psychiatry (18). Steinert et al.
described a total of seclusion and restraint in 2005–2007 between 52 and
77 (Wales 40) (19).
IT: 2002. The numbers came from two hospitals in the Modena region.
The numbers were then extrapolated to the whole of IT (18).
NL, NO, FI and DK had national registers. The numbers from NL were reported as very uncertain and could
easily be twice as high (20). The numbers from SE covered
around 20% of the population (not including the capital
region); data were deemed reasonably representative. The
data from UK and IT came from small samples, so the
data were deemed not representative. From the remaining countries, it was not possible to find any data.
Comparing the data from the three countries with
national registers that is DK, NO, FI and the numbers
from SE, which covered a reasonable part of the country,
we could see that DK more often used mechanical restraint
and holding than FI and NO. SE more often used mechanical restraint than the other countries. FI more often used
seclusion than the other countries. DK more often used
physical restraint/holding than the other countries. NO was
the country that used the smallest amount of physical coercion. It was reasonable to compare these four countries
since they were somewhat similar with respect to legislation, culture and clinical use. The countries that were most
alike probably were NO and DK, whereas the culture and
legislation were different in FI and SE.
Most intrusive coercive measures
Table 4 describes the most intrusive coercive measures
obtained from the questionnaire survey (2009). The
respondents were asked to rank the coercive measures,
from 1 to 8, 1 indicating the measure perceived as the
least intrusive and 8 the most intrusive.
300
Forced medication/long
period
Forced medication/short
period
Mechanical restraint
Seclusion/isolation
Holding/physical restraint
Time out
Constant observation
Mechanically restraint
ambulatory
5
6
8
3
5
4
3
4
2
7
2
8
1
2
7
6
3
1
2
8
4
5
3
6
4
3
1
2
5
5
7
6
3
1
2
4
5
3
2
7
6
4
1
5
2
7
3
2
1
4
1
5
1
2
Blank: Coercive measures were not in use or allowed in the country or no
reply was given, or it was ranked as “0”.
Forced medication/short period: Was defined as medicine given against the
patient’s will in an emergency (not medical treatment for a longer time
according to treatment plan).
Forced medication/long period: Was defined as medicine given against the
patient’s will, as treatment (medical treatment for a longer time according
to treatment plan).
Mechanically restraint ambulatory: Was defined as the use of restraint
devices, which allow patients to be out of bed and to walk around.
IE: No answer.
IT: No answer.
The answers from the European countries reflected
culture based differences in how coercion was perceived,
e.g. forced medication/long period was considered worst
in NO; forced medication/short period in BE; mechanical
restraint in FI, IS and FR; seclusion in the UK; holding/
physical restraint in NL and mechanical restraint ambulatory in SE, DK and IS.
The answers also showed that in the countries using
both seclusion and mechanical restraint, mechanical
restraint was regarded as the most intrusive.
Discussion and conclusions
To our knowledge, this is the first comparative study on
coercion in psychiatry trying to combine both scientific
papers and questionnaire surveys from 11 European
countries.
Background variables
A statistical evaluation of the background data (Table 1)
was not possible because of sample size, differences in
registration practice, data collection, legislation and
framework. Furthermore, some countries allowed the private sector to use coercion, others not. In some countries,
this also included the forensic area and data from the
private sector was not reported.
We found no explanation for the lower number of psychiatric beds, forced admissions and shorter mean length
of stay in IT. One explanation might be, as mentioned
NORD J PSYCHIATRY·VOL 66 NO 5·2012
COERCION IN EUROPE
earlier, not representative data, or the effect of factors not
under investigation in this paper, e.g. attitudes towards
authorities or the families’ role in caring for the patients.
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The different types of coercive measures
All countries allowed the use of forced medication in
some form. Differences in culture and history are probably the main reason for allowing and using different
coercive measures. For instance, we do not know whether
holding is used for a longer or shorter period and what
the patients perceive as more or less intrusive. This discussion could also be influenced by economy, because
holding for a long period necessitates competent and
expensive staff resources.
There were few answers from UEMS and in some
cases; they were contrary to the answers from EPSO.
The reason could be that in some countries, legislation is
implemented in practice after a delay of several months
to years.
Most intrusive coercive measures
Five of the nine countries in Europe answering the
question believe that mechanical restraint, in some form,
was the most intrusive coercive measure towards the
patients. An often-mentioned argument in countries
using mechanical restraint, against using seclusion, is
the high amount of medication used to calm the patients,
preparing them for seclusion. The only study we could
find describing this problem was “Comparisons of psychotropic drug prescribing patterns in acute psychiatric
wards across Europe (21)”, not describing the actual
relationship between coercion and medication but more
in general. What could support the above-mentioned
idea is that England is the country using the highest
dose of anti-psychotic drugs and at the same time the
only country not using mechanical restraint. On the
other hand, they used the smallest amount of anxiolytic/
bezodiazepine drugs. The study did not incorporate
depot-medication, it was a small-scale pilot study and
overall not able to confirm or reject the above idea.
However, whether mechanical restraint or seclusion is
considered more or less intrusive towards patients is in
fact unknown. In a small randomized study, Steinert &
Bergk (22) describes that “both from ethical and safety
aspects the results do not yield evidence to prefer or forbid one of the interventions. Clinical decisions should
take into account patients’ preferences.” Of course, considering patients’ preferences requires that clinicians have
the option to choose between the two kinds of coercion,
which is not the case in the UK and DK.
In the questionnaire, the countries were asked to rank
all the coercive measures, not all countries did answer as
requested. Some countries used the same number twice,
some had not used all the numbers and some had not
ranked measures they did not use themselves. However,
NORD J PSYCHIATRY·VOL 66 NO 5·2012
these discrepancies did not affect the conclusions made
above.
The number of physically coercive measures
per 100,000 inhabitants
As mentioned in the results section, the only countries,
of the 11 under investigation, that provided national public representative data were NO, FI, SE and DK. We
believe that NL after 2006 has qualified their data and
SE yet has not started, as planned, collection of nationwide data. Why other countries in Europe, beside the
Nordic countries, are not able to provide data on physical
coercive measures are unknown. One reason could be
lack of public openness; another could be that they have
a minor tradition for measuring and working with continuous quality improvement, or that some countries have
both private and public psychiatric hospitals, complicating
the collection of data, but we do not know.
What we can see is that NO used physical coercion
less than FI, SE and DK; the reason for this is unknown.
However, between 1998 and 2006, NO allocated an extra
US$576 million in running costs and US$789 million in
investments (in buildings and so on), a total of US$1.4
billion to the psychiatric area (23). During approximately
the same period, the economic growth in the psychiatric
area in DK was US$189 million (24). In addition, NO
has a long tradition of specialized education in environmental therapy of nursing staff and the number of psychiatrists in NO is 31% higher than in DK but 50%
lower than SE and 63% lower than FI. Also, legal treatment practice in NO does not have the delaying effect
of patient’s complaints on forced medication. During this
2–3-week period, where the Danish patients are not medicated, they are probably exposed to more physical coercion. How the legal treatment practices are in SE and FI
we do not know exactly. Lastly, NO used twice as much
forced admission as DK, and maybe some patients,
because of earlier treatment were exposed to less physical coercion; on the other hand FI uses even more forced
admissions. Yet the figures on forced admissions was
somewhat insecure because DK had, in 2010, 2638
forensic psychiatric patients (25), whereas NO had
mostly around 500 (we do not know the exact number)
and the forensic psychiatric patients were not a part of
the figure in Table 1. How many forensic psychiatric
patients FI and SE had we do not know but the number
of forensic psychiatric beds where quite similar to DK.
Finally, caution must be shown when trying to compare coercive measures between the different countries.
The differences in legislation, nursing and treatment culture, framework and economics make it important that
the European countries on a national level produce public data on coercion. If not, the basis for research, benchmarking and the possibility to learn from each other is
made much more difficult.
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J BAK & H AGGERNÆS
Regarding research in the area, it is evident that there
is a lack of high-quality intervention studies. One of the reasons is probably the lack of instruments that can measure
the degree of patients’ intrusive experiences of coercion.
Only one validated instrument, the Coercion Experience
Scale (26), was found.
It is very important to have scales that measure the
degree of intrusive experience, because not all mechanical restraint episodes are intrusive. From a public point
of view, it is worth noting that some people voluntarily
accept mechanical restraint, given that 10% of the psychiatric patients that were mechanically restrained in DK
were restrained voluntarily. Despite their psychotic condition, some patients seem to have such a high sense of
reality that they prefer coercion to the risk of hurting
themselves and/or others.
One could hope that in future psychiatry, we will
know when it is inevitable to choose the kind of coercion that not only is the most acceptable to the individual patient, but also convincingly is the means of least
restriction. It is obvious from the reported diversity of
the coercive measures in the present data that no country
holds the optimal solution for dealing with coercion in
psychiatry.
Acknowledgements—The authors wish to thank Mette Dons (Head of
Department, the National Board of Health, Copenhagen), Torben
Hærslev (Senior Specialist, the National Board of Health, Copenhagen) and Louise Gjørup (Administrative Assistant, the National
Board of Health, Copenhagen) for discussions and participation, and
Thomas Werge (Head of Research, Mental Health Centre Sct. Hans,
Roskilde) for valuable comments and careful reading during the
writing process.
Disclosure of interest: The project was partly funded by
the National Board of Health. There are no known conflicts of interest, financial, personal, political and academic or others. The authors are responsible for the
contents and writing the paper.
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Institute, Mental Health Centre Sct. Hans, Boserupvej 2, 4000
Roskilde, Denmark.
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Digevej 10, 2300 Copenhagen, Denmark.
Supplementary material available online
Supplementary Appendix 1 and 2.
302
NORD J PSYCHIATRY·VOL 66 NO 5·2012
Supplementary material for Bak J, Aggernæs H. Coercion within Danish psychiatry compared with 10 other European
countries. Nord J Psychiatry 2012;66:297–302.
Supplementary Appendix 1: Focused search strategy
No/database/host
Search phrase/”-string”
Date
GOOGLE Scholar
Europa lovgivning psykiatri OR psykiatrisk OR psykisk OR psykotisk
tvangsfiksering OR bæltefiksering OR fiksering OR tvang OR
tvangsmidler. Limiters—Publication Year from: 1999-, Area: Medicin,
farmakologi og veterinærvidenskab, Samfundsvidenskab, kunst og
humaniora
Restrained OR Restraint OR Restraints OR Secluded OR Seclusion OR
Coercion OR Coercive OR Containment Legislation OR Legal
Comparison OR Differences OR Variations European OR Europe OR
Europeans Mental OR Psychiatric OR Psychiatry OR Mental health OR
Mentally ill, Limiters—Publication Year from: 1999-, Area: Medicin,
farmakologi og veterinærvidenskab, Samfundsvidenskab, kunst og
humaniora
(Restrained OR Restraint OR Restraints OR Secluded OR Seclusion OR
Coercion OR Coercive OR Containment) and (Legislation OR Legal)
and (Mental OR Psychiatric OR Psychiatry OR Mental health OR
Mentally ill) and (Europe OR European OR Europeans), Limiters—
Publication Year from: 1999–, Expanders—Also search within the full
text of the articles, Search modes—Boolean/Phrase
(Ment* OR Psychiat* OR Psycho*) AND (Restrain* OR Seclu* OR
Coerc* OR Containt*) AND (Europe*) AND (Compar* OR Difference*
OR Variat*)
(Ment* OR Psychiat* OR Psycho*) AND (Restrain* OR Seclu* OR
Coerc* OR Containt*) AND (Europe*) AND (Compar* OR Difference*
OR Variat*), Date Range: 1999 to 2010
08 April 2009
24
8
4
1
15 April 2009
200
21
6
2
15 April 2009
21
3
1
1
15 April 2009
21
3
0
0
15 April 2009
2
1
1
1
15 April 2009
10
1
1
1
15 April 2009
13
0
0
0
15 April 2009
42
9
3
2
15 April 2009
10
0
0
0
15 April 2009
14
0
0
0
?
?
63
40
357
46
8
87
3
51
GOOGLE Scholar
CINAHL and
AMED/
EBSCOhost
/PubMed/
Silverplatter
Criminal justice
abstracts/
CSAILLUMINA
British Journal of
Criminology
Cochrane Library
PSYCINFO/
WebSPIRS/
OvidSP
ISI web of
knowledge
SCIRUS http://
www.scirus.
com/srsapp/
GOOGLE
different
Universities,
National Health
Boards and
others
Update
Sum
((Ment* OR Psychiat* OR Psycho*) AND (Restrain* OR Seclu* OR
Coerc* OR Containt*) AND (Europe*) AND (Compar* OR Difference*
OR Variat*)) AND PDN (⬎ 1/1/1999)
“Restrain* OR Seclu* OR Coerc* OR Containt* and Compar* OR
Difference* OR Variat* and Europe* and Ment* OR Psychiat* OR
Psycho* and Legislat* OR Legal*, from 1999 to 2009 in Cochrane
Database of Systematic Reviews”
(Restrain* or Seclusion or Coercion or Contain*) and (Comparison or
Difference* or Variation*) and Europe* and (Ment* or Psychiat* or
Psycho*) and (Legislation* or Legal*) (Including Related Terms)
(english language and abstracts and yr ⫽ “1999–2009”)
Topic ⫽ ((Ment* OR Psychiat*) AND (Restrain* OR Seclu* OR Coerc*
OR Containt*) AND (Legisla* OR Legal*) AND (Compar* OR
Difference* OR Variat*) AND Europ*)
(Ment* OR Psychiat*) AND (Restrain* OR Seclu* OR Coerc* OR
Containt*) AND (Legisla* OR Legal*) AND (Compar* OR Difference*
OR Variat*) AND Europ*, 1999–2009, Law, Medicine, Neuroscience,
Pharmacology, Psychology, Social and Behavioral Sciences, Sociology
Restrained OR Restraint OR Restraints OR Secluded OR Seclusion OR
Coercion OR Coercive OR Containment OR Psychiatric Legislation
AND Denmark OR Sweden OR Norway OR Finland OR Iceland OR
The Nederlands OR United Kingdom OR Scotland OR Ireland OR
France OR Italy (Part of titles from earlier found papers reference lists,
ex: Psykiatrian erikoisalan laitoshoito, Anvendelse af tvang i
psykiatrien, Den psykiatriske tvångvården, Inspectie voor de
Gezondheidszorg, Bruk av tvangsmidler i psykisk helsevern and so on)
April–June
2009
Result 1st sift
March 2010
2nd sift 3rd sift
1
Supplementary Appendix 2
Example from the questionnaire, the whole questionnaire can be required from the authors
2
Paper 3
Mechanical Restraint in Psychiatry:
Preventive Factors in Theory and Practice.
A Danish-Norwegian Association Study.
bs_bs_banner
Perspectives in Psychiatric Care
ISSN 0031-5990
Mechanical Restraint in Psychiatry: Preventive Factors in
Theory and Practice. A Danish–Norwegian Association Study
Jesper Bak, RN, SD, MPH, Vibeke Zoffmann, RN, MPH, PhD, Dorte Maria Sestoft, MD, PhD,
Roger Almvik, RN, RMN, Dr. Philos, and Mette Brandt-Christensen, MD, PhD
Jesper Bak, RN, SD, MPH, is PhD student, Head Nurse, Mental Health Centre Sct. Hans, Roskilde, Denmark; Vibeke Zoffmann, RN, MPH, PhD, is Senior
Researcher, Steno Diabetes Centre, Gentofte, Denmark; Dorte Maria Sestoft, MD, PhD, is Head of Department, Clinic of Forensic Psychiatry, Ministry
of Justice, Copenhagen, Denmark, Roger Almvik, RN, RMN, Dr. Philos, is Research Director, Centre for Research & Education in Forensic Psychiatry, St.
Olavs University Hospital, Forensic Department Bröset, Trondheim, Norway; and Mette Brandt-Christensen, MD, PhD, is Head of Research & Education
in Forensic Psychiatry, Mental Health Centre Sct. Hans, Roskilde, Denmark.
Search terms:
Coercion, mental health, nursing, physical
restraint, psychiatry
Author contact:
[email protected], with a copy to the
Editor: [email protected]
Conflict of Interest Statement
There are no known financial, personal, ethical,
political, academic, or other conflicts of
interest.
PURPOSE: To examine how potential mechanical restraint preventive factors in
hospitals are associated with the frequency of mechanical restraint episodes.
DESIGN AND METHODS: This study employed a retrospective association design,
and linear regression was used to assess the associations.
FINDINGS: Three mechanical restraint preventive factors were significantly associated with low rates of mechanical restraint use: mandatory review (exp[B] = .36,
p < .01), patient involvement (exp[B] = .42, p < .01), and no crowding (exp[B] = .54,
p < .01).
PRACTICE IMPLICATIONS: None of the three mechanical restraint preventive
factors presented any adverse effects; therefore, units should seriously consider
implementing these measures.
First Received April 5, 2013; Final Revision
received June 10, 2013; Accepted for
publication June 27, 2013.
doi: 10.1111/ppc.12036
In some countries, mechanical restraint (MR) can be performed legally when psychiatric inpatients pose a risk to
themselves or to others (Psykiatriloven, LBK nr. 1729, 2010).
The procedure is primarily performed by nursing staff and
involves the use of leather or fiber belts to secure the patient to
a bed. The straps are also occasionally attached around the
patient’s wrists and ankles. MR exposes patients to potential
physical risks, such as deep vein thrombosis, pulmonary
embolism, pressure sores, bone fractures, and even death
(Hem, Steen, & Opjordsmoen, 2001; Hick, Smith, & Lynch,
1999; Laursen, Jensen, Bolwig, & Olsen, 2005; Morrison &
Sadler, 2001; Nielsen, 2005). For many patients, MR produces
negative psychological effects, such as feelings of helplessness,
anger, being trapped, sadness, fear, displeasure, or offense.
Patients often regard the use of MR as an injustice or even a
punishment (Bonner, Lowe, Rawcliffe, & Wellman, 2002;
Bower, McCullough, & Timmons, 2003; Cusack, Frueh,
Hiers, Suffoletta-Maierle, & Bennett, 2003; Frueh et al.,
2005). In the worst cases, MR can cause post-traumatic stress
and lifelong trauma (Cusack et al., 2003; Frueh et al., 2005;
Steinert, Bergbauer, Schmid, & Gebhardt, 2007). These negaPerspectives in Psychiatric Care 50 (2014) 155–166
© 2013 Wiley Periodicals, Inc.
tive consequences are inconsistent with healthcare providers’
basic sense of “doing good” for the patients. Equally important arguments in favor of using MR are that healthcare professionals are obliged to secure and care for not only the
individual patient’s health and life, but also the health, lives,
and rights of others. This second obligation requires providers to prevent violence toward other patients, relatives, and
staff. Previous studies indicate that up to 10% of patients
request MR to prevent themselves from acting out (Bak &
Aggernæs, 2012). Nevertheless, the use of MR generally poses
problems, requiring that greater effort be undertaken to
reduce its frequency (Sundhedsstyrelsen, 2009).
Many factors or conditions probably influence the events
that lead to the use of MR. A lot of these conditions result
from daily activities while socializing with others in the psychiatric ward, and they can potentially be changed or prevented by mental-healthcare providers, who thereby have a
crucial role in reducing the use of MR. Numerous actions
have been recommended to reduce the use of mechanical and
physical restraints (National Risk Management Programme,
2007; The National Collaborating Centre for Nursing and
155
Mechanical Restraint in Psychiatry: Preventive Factors in Theory and Practice. A Danish–Norwegian Association Study
Supportive Care, 2005). More than 30 reviews on the management of agitation, aggression, violence, and coercion (including MR, seclusion, manual restraint, and forced medication,
among others) were identified; 10 explicitly included MR, and
all described the no high-quality research. Thus, no causal
relationship between preventive interventions and the reduction of MR episodes has been established (Johnson, 2010;
Scanlan, 2010; Steinert et al., 2010; Stewart, Van der Merve,
Bowers, Simpson, & Jones, 2010; Strout, 2010).
The most recent review (Bak, Brandt-Christensen, Sestoft,
& Zoffmann, 2012) identified numerous MR-preventive
factors based on studies specifically targeting MR prevention.
No MR-preventive factors found in the review were based on
the highest scientific-recommendation grade (see grading
levels in the review). Furthermore, several of these MRpreventive factors might be effective only in controlled
research environments. Thus, the applicability and impact of
these MR-preventive factors in everyday practice remain
unknown.
In 2008, a critical public debate concerning the use of MR
in Denmark led to a comparative study on the use of coercion
in 11 European countries, including Denmark (Bak &
Aggernæs, 2012). Few of the included countries had national
statistics available on the use of MR. Finland, Norway, and
Denmark had valid nationwide statistics, as did the Netherlands and Sweden, to some extent (Bak & Aggernæs, 2012).
Norway had the lowest rate of physical coercion (MR, seclusion, and physical restraint/holding), with 29 people per
100,000 inhabitants having experienced physical coercion.
Compared to Denmark, which had 122 episodes of MR
per 100,000 inhabitants, Norway had 87 episodes of MR
per 100,000 inhabitants in 2007 (Bremmes, Hatling, &
Bjørngaard, 2008; Sundhedsstyrelsen, 2008). Because the
lower frequency of MR episodes in Norway might indicate
that more effective MR-preventive factors have been implemented there compared to Denmark, we presumed that
including both countries in this study might generate new
knowledge. In addition, a cross-country study was possible
because the national legislations, administrative structures,
and cultures of these nations are similar.
movement (Bowers et al., 2007). Note that this definition
refers only to the restraint of inpatients in psychiatric hospitals. A retrospective association study was conducted to investigate the degree to which the nonmedical MR-preventive
factors identified in a previous review (Bak et al., 2012) were
implemented in the psychiatric units of Denmark and
Norway. Next, we investigated whether the chosen factors
were associated with the number of MR episodes.
The following conditions must be present to legally initiate
MR according to the Danish Mental Health Act (translated by
the authors):
Mechanical restraint may be used only when necessary to
prevent a patient from
1. exposing their body or health or the body or health of
others to danger,
2. pursuing or in any other way grossly molesting fellow
patients, or
3. committing significant acts of vandalism.
(Psykiatriloven, LBK nr. 1729, 2010)
These conditions are consistent with Norwegian legislation
(translated by the authors):
Restraints may be used on a patient only when absolutely
necessary to prevent him or her from damaging him or
herself or others or to prevent damage to buildings,
clothing, inventory or other things. (Lov nr. 62, 1999)
The MR-preventive factors identified by the literature review
(Bak et al., 2012) were included in an online questionnaire
sent to the clinical nurse managers for the purpose of quantifying whether they were implemented in the units. These
managers were chosen because they had exclusive access to
the requested information. The units were the smallest organizational collection of beds led by a clinical nurse manager.
Time Frame
The questionnaire was administered between December 23,
2009, and January 27, 2011. The collected data pertained to
2008 in Denmark and 2010 in Norway.
Included Participants
Purpose
The goal of this study was to provide a basis for developing
MR-preventive practices by answering the following question: How are presumed MR-preventive factors of nonmedical origin associated with the frequency of MR episodes in
Denmark and Norway?
Design and Methods
This paper uses Bowers et al.’s (2007) definition of MR: The
use of restraining straps, belts, or other equipment to restrict
156
All psychiatric hospital units in Denmark (87) and Norway
(96) that treated adult inpatients (18–65 years) in which MR
had been used for approximately two years prior to the year of
investigation were included in the study. The clinical nurse
manager of each unit provided the requested information by
answering the questionnaire. The units were identified by
contacting the clinical heads of the departments. In
Denmark, the departments were selected from the national
register on coercion; in Norway, they were selected by contacting the administrators of the health regions and the
researchers already working in the area.
Perspectives in Psychiatric Care 50 (2014) 155–166
© 2013 Wiley Periodicals, Inc.
Mechanical Restraint in Psychiatry: Preventive Factors in Theory and Practice. A Danish–Norwegian Association Study
Table 1. Hierarchy of Preventive Factors That Might Decrease the Use of MR
Rank
MR-Preventive Factor
Rank
MR-Preventive Factor
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Cognitive milieu therapy and patient involvement
Combined intervention programs
Patient-centered care and patient involvement
Identification of the patient’s crisis triggers
Risk assessment
Treatment of substance abuse and psychosis
Mandatory review (e.g., post-incident review)
Staff training
Staff attitudes
Patient–staff ratio
Staff education
Staff experience
Patients perceived as a resource in their own treatment
p.n. medication guided by individual patients
15
16
17
18
19
20
21
22
23
24
25
26
27
Debriefing, defusing, and crisis intervention
Patient’s positive responses to rules
Activity-based nursing
Working environmental factors
No crowding
Regular staff–substitute ratio
Staff opposition to MR
Alarm systems
Care alliance
Communication (communicative de-escalation)
Well-maintained and familiar surroundings
Music used as a diversion and for relaxation
Separation of acutely disturbed patients
Note. Rank refers to the decreasing order in the hierarchy of effect and recommendation grade (Bak et al., 2012). p.n. medication, pro necessitate/asneeded medication; MR, mechanical restraint.
Excluded Participants
The special high-security department in Denmark was
excluded because specific legislation concerning seclusion/
isolation was in effect. MR did occur in Norway in settings
other than hospitals; however, because only 1.5% of recorded
Norwegian MR episodes in 2007 occurred in these settings
(Bremmes et al., 2008) and because the primary focus of this
study was hospitals, these units were also excluded.
Excluded Outcome Data
If MR was used more than 25 times on the same patient
during the investigation period, then these data were
excluded. Chance determined the units to which these
patients were admitted, but their presence significantly
affected the unit MR frequency, distorting the results.
Data Collection: The Questionnaire
A questionnaire was developed based on the results from an
earlier systematic literature review that focused on factors
that might reduce the use of MR (Bak et al., 2012). The found
MR-preventive factors can be found in Table 1. For a more
thorough description, see Bak et al. (2012).
Every MR-preventive factor was“translated”into questions
to identify the degree to which the factor was present in the
units. Six factors were not included in the present study.
Number 2 (combined intervention programs) was omitted
because it was too complex to measure. The following factors
were omitted because they were not considered to be measured appropriately by the questionnaire: Number 6 (treatment of substance abuse and psychosis), Number 13 (patients
perceived as a resource in their own treatment), Number 14
Perspectives in Psychiatric Care 50 (2014) 155–166
© 2013 Wiley Periodicals, Inc.
(pro necessitate/as-needed medication guided by individual
patients), Number 23 (care alliance), and Number 26 (music
used as a diversion and for relaxation). Numbers 1 (cognitive
milieu therapy and patient involvement) and 3 (patientcentered care and patient involvement) were separated into
three factors: cognitive milieu therapy, patient-centered care,
and patient involvement. Although patient involvement is
part of cognitive milieu therapy and patient-centered care, it
might also occur by itself.
The questionnaire was developed by conceptualizing and
operationalizing the MR-preventive factors. To increase
validity and reliability, we followed the Question Appraisal
System (QAS-99; Willis & Lessler, 1999) that was developed to
identify problems in questionnaires, including the cognitive
processes inherent to the question-answering process.
The construction and pretesting of the questionnaire
involved an eight-step appraisal of each item (QAS-99):
reading, instructions, clarity, assumption, knowledge/
memory, sensitivity/bias, response categories, and others.1
The pretest was conducted by creating a cognitive-test protocol that included probes for each item. The probes covered the
aforementioned eight steps and consisted of seven types:
general, specific, understanding/interpretation, safety,
1
Step 1: Reading: Determine if it is difficult for the interviewers to read the
question uniformly to all respondents. Step 2: Instructions: Look for problems
with any introductions, instructions, or explanations from the respondent’s
point of view. Step 3: Clarity: Identify problems related to communicating the
intent or meaning of the question to the respondent. Step 4: Assumptions:
Determine whether there are problems with assumptions or the underlying
logic. Step 5: Knowledge/Memory: Check whether respondents are likely to
not know or have trouble remembering information. Step 6: Sensitivity/Bias:
Assess questions for sensitive nature or wording, and for bias. Step 7: Response
categories: Assess the adequacy of the range of responses to be recorded. Step
8: Other: Look for problems not identified in Steps 1–7 (Willis & Lessler,
1999).
157
Mechanical Restraint in Psychiatry: Preventive Factors in Theory and Practice. A Danish–Norwegian Association Study
paraphrasing, and memory (e.g., how did you reach this
answer, how do you define physical activity, etc.).
The pretest consisted of cognitive interviewing (Willis,
2005) four clinical nurse managers individually using concurrent probing (Watt et al., 2008) in which verbal probes were
asked immediately after a question. This protocol led to the
revision of seven questions that were subsequently pretested
in a group interview.
Data collection, administration, and processing, as well as
error identification and the creation of electronic data files
(Olsen, 2006; Schaeffer & Presser, 2003), were administered
using the electronic web-based survey system Enalyzer
Survey Solution, Version 2010 (Enalyzer A/S, Copenhagen,
Denmark).
The questionnaire was checked for test–retest reliability by
asking three clinical nurse managers to answer the questionnaire a second time after a 3-month interval (the respondents
were instructed not to check their previous answers). The
estimated mean correlation between all of the first and second
answers was reasonable (Kendall’s Taub [τKen,b] = .75). With
regard to the Norwegian portion of the study, the questionnaire was translated and retranslated by JB and then checked
by two healthcare professionals who were familiar with the
subject. A pretest was conducted to test face validity through
cognitive interviewing seven clinical nurse managers. This
test led to the revision of eight questions, mostly due to
imprecise translations. Moreover, one question was added to
the questionnaire due to different staff competences: Psychologists in Norway are partially responsible for their
patients’ treatment, which is not the case in Denmark.
Later, the outcome variable (i.e., the number of MR episodes) was reexamined. This procedure was necessary due to
the confusing wording of a heading in the Danish questionnaire and the lack of precise numbers regarding the Norwegian patients who experienced MR more than 25 times (14
answer categories instead of the actual number were provided, which made the exclusion imprecise). The reexamination was accomplished by contacting all of the clinical nurse
managers in Denmark and four of the clinical nurse managers
in Norway. The respondent rate was 94%, and the results
lowered the overall frequency of MR by 3.2%. A high correlation coefficient (τKen,b = .89) was found between the two
answers, revealing that the confusing headline and the categorization error did not have an important effect.
From Review to Data Analyses
The flowchart in Figure 1 shows an example of transforming
the findings in the literature review to the final analyses. The
Danish and Norwegian questionnaire can be obtained from
the authors.
All dichotomized MR-preventive factors can be found in
Table 2.
158
Literature review
The literature review revealed that two studies found that the
preventative factor “Mandatory review” was most likely associated
with the use of MR. Specifically, MR-reduction rates were between
36% and 62%.
Questionnaire
The questionnaire was created using a conversion process in which
the factor was “translated” into a question (e.g., did you audit,
review or conduct a similar systematic follow-up after the MR
events to analyze and learn from them?)
The question was measured using five levels:
1. Yes, after all MR incidents
2. Yes, after ¾ of all MR incidents
3. Yes, after ½ of all MR incidents
4. Yes, after ¼ of all MR incidents
5. No
Combining the questions into a dichotomized factor
The dichotomization of the five levels in the question was
accomplished by examining the two papers from the literature
review. One review was conducted after all MR episodes, and the
other was conducted after six events or one long-lasting MR
episode. The unit and department staff conducted the review in both
papers. The above question does not answer whether this is the case
in the actual unit. Therefore, we decided that the dichotomization
should be conducted after all MR incidents, rather than after those
that are fewer or newer.
Data analyses
Finally, we analyzed whether associations existed among the outcome
variable (the numbers of MR incidents), the background variables, and
the preventive factor.
Figure 1. Flowchart “From review to Data Analyses”
An example of the possible MR-preventive factor “Mandatory review”
from the literature review. Qualified clinical experts should conduct
mandatory post-incident reviews because they minimize the number of
MR episodes. MR, mechanical restraint.
The Outcome Variable
The outcome variable was the number of MR episodes per
unit over 1 year.
Potential Confounders
Several conditions may be associated with both the frequency
of MR use and the presence of the preventive factors in the
units; therefore, they must be treated as covariates in the estimation of the associations between the preventive factors and
the outcome variable.
These conditions were geography (Bremmes et al., 2008;
Keski-Valkama et al., 2007), unit size, bed occupancy, type of
bed, reason for the MR, forensic provision, ethnicity other
Perspectives in Psychiatric Care 50 (2014) 155–166
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Mechanical Restraint in Psychiatry: Preventive Factors in Theory and Practice. A Danish–Norwegian Association Study
Table 2. A Description of How the MR-Preventive Factors Were Measured
MR-Preventive Factors
Measurement Description
Cognitive milieu therapy vs. no
cognitive milieu therapy
The clinical nurse manager described the care in his or her unit as “cognitive behaviour therapy” or “cognitive
milieu therapy,” and the staff had participated in 40 hr of training or more in this care method—The care
method was not described.
One of the following factors was present: the patients participated in ward rounds/conferences, influenced
the rules imposed by the unit, or influenced what was written in the nurse’s journal—Patients did not
participate in these areas.
The clinical nurse manger described the care in his or her unit using the words “individual,” and
“cooperative,” or “patient-centred,” and the staff had participated in 40 hr of training or more in this care
method—These words were not used to describe this care method.
The initial nurse evaluation of at-risk patients always contained a written evaluation of aggressive,
self-mutilating, or suicidal behaviors (e.g., crisis triggers, unique calming techniques, and coping
strategies)—The initial evaluation only sometimes or never contained a written evaluation.
The risk of developing aggressive/violent or self-mutilating/suicidal behaviors was always systematically
evaluated and documented, and care actions were initiated—These behaviors were only sometimes or
never evaluated and documented.
An audit, review, or similar systematic follow-up evaluation was conducted after all MR episodes—The
evaluation was only conducted after some or none of the MR episodes.
An average of 50% or more of the staff had participated in training regarding de-escalation, avoiding physical
attacks, careful restraining techniques, legislation, MR predictors/antecedents, and suicide prevention—Less
than 50% of the staff had such training.
All staff directed their attention toward the patient and possessed communicative skills, optimism, and
empathy—Not all of the staff possessed these skills.
The staff-to-patient ratio was higher than or equal to three-to-one on average—This ratio was lower than
three-to-one on average.
The staff had received basic training for at least 3 years—The staff had less than 3 years of training.
The experience of the staff in the psychiatric specialty was more than 5 years on average—Staff experience
was 5 years or fewer.
Follow-up evaluations were initiated after each MR episode for debriefing, defusing, or other crisis
interventions—No follow-up was initiated.
The patients reacted positively to the rules, and limit-setting was motivational—The opposite occurred.
Patient involvement vs. no patient
involvement
Patient-centered care vs. no
patient-centered care
Identification of the patient′s crisis
triggers vs. no identification
Risk assessment vs. no risk
assessment
Mandatory review vs. no mandatory
review
Staff training (> 50% vs. less)
Positive staff attitudes vs. less positive
Patient–staff ratio (≥ 3 staff per
patient vs. fewer)
Staff education (≥ 3 years vs. fewer)
Staff experience (> 5 years vs. fewer)
Debriefing, defusing vs. none
Positive patient responses to rules vs.
negative responses
Activity-based nursing vs. no
activity-based nursing
Acceptable work environment vs.
poor work environment
No crowding vs. crowding
Substitute staff (< 50 vs. more)
Staff opposition to MR (many vs.
some)
Alarm systems (many and
well-trained responses vs. less
well-trained responses)
Communication (all staff have
communicative skills vs. less that
all)
Well-maintained, clean, and tidy
surroundings (always vs. seldom)
Separation of acutely disturbed
patients vs. no separation
Individual patient-activity plans were devised, and the patients participated in many or several physical or
other-type activities—The patients had no activity plans, and they participated in few or no physical or other
activities.
Presence of a workplace assessment, no or only insignificant physical or mental work-environment problems
existed, and the overall work environment was evaluated as acceptable—The work environment was not
evaluated, more work-environment problems existed, and the overall work environment was evaluated as
poor.
Two of the following three factors were present for no crowding: only one bed in a patient’s room, more than
25 m2 of all-day-accessible space per patient, and the perception of no crowding—Only one or none of
these factors was present.
Substitute staff was used less than 50 times (8-hr shifts) over the year—These employees were used more
than or equal to 50 times.
All staff had the attitude that “MR should be initiated rarely to protect the lives of the patient and
others”—Not all staff had this attitude.
More than three night-shift staff members responded to an alarm call, and they were all trained in this
task—Not all such staff were trained, or they were trained but failed to respond.
All staff had general communicative skills or special skills with regard to communicative de-escalation—Less
than all the staff had these skills.
The unit was perceived as well maintained, clean, and tidy—The perceptions were otherwise.
The unit was able to separate acutely disturbed patients from other patients—The unit was unable to do so.
MR, mechanical restraint.
Perspectives in Psychiatric Care 50 (2014) 155–166
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Mechanical Restraint in Psychiatry: Preventive Factors in Theory and Practice. A Danish–Norwegian Association Study
Table 3. Potential Confounders
Number of MRs per Unit
Potential Confounders
Geography
Unit size
Bed occupancya
Type of bed
Reason for the MRa
Forensic provision
Ethnicity
Type of unit
Helse Sør-Øst RHF
Helse Vest RHF
Helse Midt-Norge RHF
Helse Nord RHF
Region Hovedstaden
Region Sjælland
Region Syddanmark
Region Midtjylland and Nordjylland
0–9 beds
10–19 beds
More than 20 beds
≤ 100% occupancy rate
> 100% occupancy rate
Closed
Shielded or integrated
Open or other
Self-mutilation or suicidal behaviors
Aggressive behaviors or “acting out”
≤ 20.65% of patients with a forensic provision
> 20.65% of patients with a forensic provision
≤ 10.6% of patients with an ethnic background
other than Danish/Norwegian
> 10.6% of patients with an ethnic background
other than Danish/Norwegian
Acute
Forensic/secure
Special/rehabilitation/long term
Missing
n
Mean
Range
0
26
6
10
6
16
6
8
12
16
63
11
78
11
61
16
13
87
87
64
23
51
26
31
9
11
28
39
94
40
17
37
26
34
21
34
42
16
8
25
32
34
32
0–74
4–64
0–22
2–21
0–254
2–105
38–184
0–87
0–50
0–254
0–108
0–254
3–87
0–254
0–184
2–64
0–150
0–170
0–184
2–254
0–184
32
34
1–254
55
23
12
40
26
12
0–254
0–184
0–31
0
1
0
3
3
7
0
Note. aUsed as continuous variable in the further analyses. MR, mechanical restraint. RHF, regionale helseforetak.
than Danish/Norwegian (Knutzen, Sandvik, Hauff,
Opjordsmoen, & Friis, 2007; Norredam, Garcia Lopez,
Keiding, & Krasnik, 2010), and type of unit (De Benedictis
et al., 2011). See the distributions in Table 3.
Other variables (e.g., the diagnostic distribution among
patients, the unit’s population base, patient flow, age, medication and types of therapy, or other treatment activities)
could affect the outcome; however, these variables were
either not the focus of this study (nonmedical factors,
including medication and types of therapy) or “covered” in
the earlier mentioned covariates, as unit type and geographic region acted as proxy covariates (e.g., diagnostic distribution, patient flow, and age were included in unit type;
country was included in geographic region; and the population base was included both in the unit type and the geographic region).
Gender is most likely not associated with MR
(Keski-Valkama et al., 2010; Knutzen et al., 2007); thus, we
did not use it as a covariate. The number of patients who
experienced MR and time spent in MR was closely related to
the number of MR episodes; therefore, these factors were not
confounders.
160
Data Analyses
The data analyses were conducted in four steps. First, we analyzed how the factors were individually associated with the
number of MR episodes (Model 1). Second, we analyzed how
the factors were associated with the number of MR episodes,
using a model with all factors included (Model 2). Third, to
eliminate multicollinearity and the chance that important
effects may hide each other from Model 2, a third model was
constructed by a forward factor-selection procedure, where
the most significant factors were included stepwise until the
corrected quasi-likelihood under independence model criterion value began to rise, denoting no further improvement
for the model (Model 3). All these models were additionally
adjusted for the potentially confounding variables. Additionally, we adjusted for nesting of units in departments—17
departments contained two units each, and three departments contained three units each—by a generalized estimating equations technique. Finally, we analyzed the correlation
between the factors by Pearson’s correlation coefficient,
adjusted for department, to explore multicollinearity and
justify a reduction of Model 2.
Perspectives in Psychiatric Care 50 (2014) 155–166
© 2013 Wiley Periodicals, Inc.
Mechanical Restraint in Psychiatry: Preventive Factors in Theory and Practice. A Danish–Norwegian Association Study
In Models 1–3, linear regression was used to assess the associations between the number of MR episodes and the chosen
factors. To stabilize the variance, the outcome was logarithmically transformed. Hence, the regression coefficients are
reported back-transformed (exponentiated; exp(B)) and are
to be interpreted multiplicatively. Hence, because the preventive factors were dichotomized, a regression coefficient
exp(B) indicates the average number of times MR increased
for units where this factor was present compared to units
where this factor was absent. Even though the outcome is a
count, for which a Poisson regression may often be used, the
linear regression fit the data better, for example, the quasilikelihood under independence model criterion value was
more than twice as high using Poisson regression.
To account for multiple testing, a p value < .01 was chosen
to indicate significance. All analyses were performed using
IBM SPSS Statistics for Windows, Version 19.0 (Released
2010. IBM Corp, Armonk, NY, USA).
Denmark
(n = 87)
Norway
(n = 96)
Excluded: special
high-security
forensic units
(n = 3)
Norway does not
have special highsecurity units
(n = 0)
Nonresponders/
Refused/Missing
data (n = 41)
Nonresponders/
Refused/Missing
data (n = 49)
Included
(n = 43)
Included
(n = 47)
Participants from Denmark and Norway
(n = 90)
Figure 2. Flowchart of the Participating Units
Number of MR episodes
Approval and Ethics
Questionnaires such as the one included in the present study
do not require approval from the scientific-ethical committee
system in Denmark or Norway when the respondents are able
to provide informed consent or when sensitive information is
not collected. The Danish Data Protection Agency (Journal
number: 2007-2058-0015, PSV-2009-2013) approved this
study,and we received permission from the Danish Health and
Medicines Authorities and the Danish Psychiatric Central
Research Register to use the register data on the frequency of
MR in Denmark (Munk-Jørgensen & Mortensen, 1997).
This study followed the Ethical Guidelines for Nursing
Research in the Nordic Countries (Northern Nurse Federation,
2003) and the Recommendations on Legal Protection of Persons
Suffering From Mental Disorders Especially Those Placed as
Involuntary Patients (Council of Europe, 2000).
Findings
Flow of Participating Study Units
Figure 2 displays a flowchart of the participating units.
Respondents
The responding and nonresponding units were equally distributed across the countries (response rate = 49%). Clinical
nurse managers did not respond for the following reasons, as
provided by managers: “change of clinical nurse manager” (n
= 9), “lack of personal resources for accomplishing the task”
(n = 7), sick leave (n = 5), inability to remember/identify the
number of MR episodes (n = 5), lack of belief that this type of
research was beneficial (n = 1). The remaining 63 did not
provide a reason.
Perspectives in Psychiatric Care 50 (2014) 155–166
© 2013 Wiley Periodicals, Inc.
The respondents reported 2,361 MR episodes in Denmark
and 1,017 MR episodes in Norway during the examined time
periods. Nine units accounted for 451 of the excluded MR
episodes (>25 per person), leaving 1,938 episodes in
Denmark and 989 in Norway for analysis.
Estimating Associations
The outcome variable (the number of MR episodes during
1 year per unit) varied between 0 and 254, with a mean value
of 32.5. Alternatively, the number of MR episodes per year per
bed varied between 0 and 15.9, with a mean value of 2.5.
In Table 4, Model 1, one MR-preventive factor was significantly associated with a low frequency of MR episodes: mandatory review (exp(B) = .41, p < .01).
In Model 2, seven MR-preventive factors were significantly
associated with a low frequency of MR episodes: patient
involvement (exp(B) = .14, p < .01), staff education (exp(B) =
.14, p < .01), mandatory review (exp(B) = .27, p < .01), positive
patient responses to rules (exp(B) = .34, p < .01), staff experience (exp(B) = .40, p < .01), identification of the patient’s
crisis triggers (exp(B) = .45, p < .01), and no crowding (exp(B)
= .50, p < .01). One MR-preventive factor was significantly
associated with a high frequency of MR episodes: staff training (exp(B) = 3.60, p < .01).
In Model 3, three MR-preventive factors were significantly
associated with a low frequency of MR episodes: mandatory
review (exp(B) = .36, p < .01), patient involvement (exp(B) =
.42, p < .01), and no crowding (exp(B) = .54, p < .01).
The Pearson’s correlation matrix showed one highly
(Pearson’s r > .50) intercorrelated pair: communication and
positive staff attitudes (Pearson’s r = .77). Furthermore, six
pairs showed medium intercorrelation (Pearson’s r .30 ≤ .50):
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Mechanical Restraint in Psychiatry: Preventive Factors in Theory and Practice. A Danish–Norwegian Association Study
Table 4. Effects of Potential MR-Preventive Factors on the Annual Number of MR Episodes
Model 1
Model 2
Model 3
MR-Preventive Factors
exp(B)
95% CIs of
exp(B)
p
exp(B)
95% CIs of
exp(B)
p
exp(B)
95% CIs of
exp(B)
p
Cognitive milieu therapy vs. no cognitive milieu therapy
Patient involvement vs. no patient involvement
Patient-centered care vs. no patient-centered care
Identification of the patient’s crisis triggers vs. no
identification
Risk assessment vs. no risk assessment
Mandatory review vs. no mandatory review
Staff training (> 50% vs. less)
Positive staff attitudes vs. less positive
Patient-staff ratio (≥ 3 staff per patient vs. less)
Staff education (≥ 3 years vs. less)
Staff experience (> 5 years vs. less)
Debriefing, defusing vs. none
Positive patient responses to rules vs. negative responses
Activity-based nursing vs. no activity-based nursing
Acceptable work environment vs. poor work environment
No crowding vs. crowding
Substitute staff (< 50 vs. more)
Staff opposition to MR (many vs. some)
Alarm systems (many and well-trained responses vs. less
well-trained responses)
Communication (all staff have communicative skills vs.
less that all)
Well-maintained, clean, and tidy surroundings (always
vs. seldom)
Separation of acutely disturbed patients vs. no separation
0.75
0.51
0.79
0.73
[0.26,
[0.29,
[0.30,
[0.46,
2.07]
0.88]
2.06]
1.15]
.57
.02
.62
.17
0.67
0.14*
0.42
0.45*
[0.37,
[0.07,
[0.17,
[0.29,
1.18]
0.30]
1.01]
0.72]
.17
.00
.05
.00
–
0.42*
–
–
–
[0.25, 0.73]
–
–
–
.00
–
–
2.01
0.41*
1.08
1.15
0.72
1.16
0.76
1.20
0.82
0.93
0.54
0.56
0.82
0.85
1.12
[0.84,
[0.23,
[0.69,
[0.61,
[0.42,
[0.39,
[0.47,
[0.81,
[0.46,
[0.51,
[0.33,
[0.34,
[0.51,
[0.54,
[0.42,
4.81]
0.73]
1.69]
2.16]
1.24]
3.41]
1.23]
1.70]
1.47]
1.70]
0.90]
0.92]
1.32]
1.34]
3.00]
.12
.00
.74
.67
.24
.79
.27
.36
.50
.82
.02
.02
.42
.49
.82
2.91
0.27*
3.60*
1.15
1.36
0.14*
0.40*
0.85
0.34*
1.65
1.09
0.50*
0.57
1.12
2.31
[1.28,
[0.18,
[2.49,
[0.58,
[0.83,
[0.06,
[0.24,
[0.59,
[0.19,
[1.08,
[0.76,
[0.31,
[0.33,
[0.77,
[1.15,
6.60]
0.39]
5.20]
2.26]
2.21]
0.32]
0.67]
1.22]
0.62]
2.51]
1.58]
0.80]
1.01]
1.62]
4.63]
.01
.00
.00
.69
.22
.00
.00
.39
.00
.02
.64
.00
.05
.56
.02
–
0.36*
–
–
–
–
–
–
–
–
–
0.54*
–
–
–
–
[0.21, 0.63]
–
–
–
–
–
–
–
–
–
[0.36, 0.81]
–
–
–
–
.00
–
–
–
–
–
–
–
–
–
.00
–
–
–
1.08
[0.66, 1.75]
.77
1.53
[0.84, 2.81]
.17
–
–
–
0.69
[0.41, 1.17]
.17
1.08
[0.71, 1.66]
.72
–
–
–
1.55
[0.95, 2.52]
.08
1.14
[0.73, 1.78]
.57
1.65
[1.10, 2.49]
.02
Note. The exp(B) parameters were estimated using a linear regression, and all three models were adjusted for the background variables: geography, unit
size, bed occupancy, type of bed, reason for the MR, forensic provision, ethnicity, and type of unit. Additionally, the nesting of units in departments
was adjusted for by generalized estimating equations techniques. In Model 1, the MR-preventive factors were analyzed alone. In Model 2, all the
MR-preventive factors were analyzed together. In Model 3, a forward-selection procedure included the most significant MR-preventive factors until the
Corrected quasi-likelihood under independence model criterion value began to rise. In all three models, the outcome variable (i.e., the number of MR
episodes) was log-transformed. Hence, the parameters should be interpreted multiplicatively (e.g., in Model 1, cognitive milieu therapy results in 0.75
times the average number of MR incidents without cognitive milieu therapy or 25% fewer MR episodes occur with cognitive milieu therapy than
without). *p < .01. MR, mechanical restraint.
patient-centered care and cognitive milieu therapy (Pearson’s
r = .49); communication and staff opposition to MR
(Pearson’s r = .38); substitute staff and activity-based nursing (Pearson’s r = .36); communication and risk assessment
(Pearson’s r = .32); positive patient responses to rules and
identification of the patient’s crisis triggers (Pearson’s r =
.31); and staff education and cognitive milieu therapy
(Pearson’s r = .31). All correlations were significant (p < .01).
Patient involvement, mandatory review, and crowding
were the only potential MR-preventive factors that had a significant effect (p < .01) in Model 3. The parameter estimates
(exp(B) = .36, .42, and .54) are interpreted below.
Mandatory review: Units in which the staff audited,
reviewed, or conducted a similar systematic follow-up evaluation after all MR episodes (to analyze and learn from the
162
episodes) experienced an average of .36 times as many (or
64% fewer) MR episodes than did those where the evaluation
was conducted after some or none of the MR episodes.
Patient involvement: Units in which the patients participated in ward rounds/conferences, influenced the rules
applied to the unit, or influenced what was written in the
nurse’s journal experienced an average of .42 times as many
(or 58% fewer) MR episodes than those in units in which no
such participation existed.
Crowding: Units in which two of the following three conditions were present experienced an average of .54 times (or
46% fewer) MR episodes than those in units where only one
or none of the conditions was present: only one bed in a
patient’s room, more than 25 m2 of all-day-accessible space
per patient, and the perception of no crowding.
Perspectives in Psychiatric Care 50 (2014) 155–166
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Mechanical Restraint in Psychiatry: Preventive Factors in Theory and Practice. A Danish–Norwegian Association Study
Discussion
Mandatory review was significant in all three models; correspondingly, no significant intercorrelations were found with
the other factors. Thus, no other factors greatly influenced the
association between mandatory review and the number of
MR episodes. Previous research also reported that conducting
mandatory reviews of MR episodes was associated with a low
number of MR episodes (Donat, 1998, 2003; McCue, Urcuyo,
Lilu, Tobias, & Chambers, 2004; Pollard, Yanasak, Rogers, &
Tapp, 2007; Prescott, Madden, Dennis, Tisher, & Wingate,
2007). The previous research has suggested that an optimal
process should review all MR episodes within a few days and
that the review board should consist of an interdisciplinary
team that includes a nurse specialist, a physician, a psychologist, and the clinical department heads with the supervisory
authority to change nursing and treatment practices. In addition, the review process should require a protocol that
includes a description of the episode, the environmental conditions that might have provoked the problem behavior, possible “crisis triggers” and any unique calming techniques
identified, the ways in which the patient is involved, their
medications, any behavioral treatments and milieu therapies,
and other items.
Patient involvement was significant in both Model 2 and
Model 3; because patient involvement was not significant in
Model 1, minor intercorrelations did occur (albeit not
strongly or significantly) with, for example, staff training and
well-maintained, clean, and tidy surroundings. Potentially,
elements of patient involvement are included in some staff
training, and patients who are more involved in their own
care may have a greater sense of responsibility toward their
surroundings. Thus, the nonsignificant and highly complex
statistics in the correlation matrix with regard to patient
involvement did not precisely explain which factors influenced the association between patient involvement and the
number of MR episodes. Previous research also reported that
patient involvement might reduce MR episodes (Borckardt
et al., 2011; Thyrsting & Hall, 2008). In our study, patient
involvement was measured using three items (whether the
patients participated in ward rounds/conferences, as well as
whether they influenced the rules and what was written in
nurses’ journals). Of course, patient involvement is a much
more complex phenomenon that includes the concept that
the patient is the expert on his or her life, and the staff is expert
with regard to their care or treatment; actions are negotiated
via dialog. It is, however, reasonable to believe that units with
a recovery-orientated or an empowering approach, that integrate patient involvement in the delivery of care and treatment, will include one of the aforementioned items (whether
the patients participated in ward rounds/conferences, as well
as whether they influenced the rules and what was written in
nurses’ journals).
Perspectives in Psychiatric Care 50 (2014) 155–166
© 2013 Wiley Periodicals, Inc.
No crowding was significant in both Model 2 and Model 3;
one minor but significant intercorrelation between no crowding and patient/staff ratio existed (Pearson’s r, .24, p < .05).
This intercorrelation is understandable, where more staff
creates a perception of more crowding. Previous research also
reported that no crowding might influence the number of
MR episodes (Meehan, McIntosh, & Bergen, 2006; Vaaler,
Morken, Fløvig, Iversen, & Linaker, 2006; van der Schaaf,
Dusseldorp, Keuning, Janssen, & Noorthoorn, 2013;
Virtanen et al., 2011).
Several MR-preventive factors had high parameter estimates that indicated an increase in the number of MR episodes, although none was significant in Model 3. One of the
most interesting was risk assessment; strong evidence supported the role of this preventive factor in earlier studies,
including at least two cluster randomized controlled trials
(RCTs). One study showed a reduction in coercive measures
(Abderhalden et al., 2008), and the other showed a reduction
in aggressive incidents (van de Sande et al., 2011). The reason
we did not find a significant relationship between risk assessment and MR reduction in our study might be that we combined the risk assessments for self-destructive/suicidal
behaviors and aggressive/violent behaviors. The difference in
the risk assessments of self-destructive behaviors is most
likely impossible to measure because both Denmark and
Norway have focused on this factor over the past several years;
thus, almost all institutions have implemented this system of
assessment. Assessment of aggressive/violent behavior has
also become more common. Fifty-five percent of the patients
were systematically assessed for the risk of developing aggressive or violent behaviors in the units; however, this assessment
system appears to have been introduced initially in units with
high numbers of MR episodes. Therefore, risk assessment
must be investigated by another means (e.g., single riskassessment methods using a cluster-RCT design). The same
pattern could be seen with staff training, which was the only
significant factor with high parameter estimates, though only
in Model 2. Training in de-escalation, avoiding physical
attacks, careful restraining techniques, etc., were likely offered
first to staff in units with high numbers of MR episodes.
Overall, because the quality of the supporting research
does not establish a causal relationship between the number
of MR episodes and mandatory review, patient involvement,
or no crowding, the findings of this study cannot be seen as a
rejection of hypotheses in practice; rather, they support and
provide a better understanding of the mechanisms involved
in MR prevention.
Limitations
Several limitations must be considered when examining the
results. First, some confounding covariates might be missing
from the analyses. This basic limitation is embedded in the
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Mechanical Restraint in Psychiatry: Preventive Factors in Theory and Practice. A Danish–Norwegian Association Study
study design, given that there was no controlled laboratory
environment and that it was not possible to control all potential covariates (e.g., patient flow, diagnostic distribution, the
units’ different population bases, and age of the patients who
experienced MR); however, either these covariates are not
associated with the number of MR episodes, or their effect
disappeared after geographic region and type of unit were
added to the analyses of the data from the Danish National
Register on coercion, where they acted as proxy covariates.
The two datasets (the questionnaire and the Danish National
Register on coercion) were obtained from different organizational levels (units/wards) in the same year, which leads us to
believe that the same effect might be found in our questionnaire data (the covariates without confounding); however, we
did not have access to these data from the Norwegian sample;
therefore, we do not know whether these conclusions apply to
the entire dataset.
Second, recall bias is possible, especially for the Danish
data; the clinical nurse manager had to recall all MRpreventive factors and the conditions and number of MR episodes from 2 years prior. The outcome variable (i.e., the
number of MR episodes) and the number of patients who
experienced MR more than 25 times were validated or reexamined (see the Data Collection section). This analysis did
not reveal significant recall bias with regard to the outcome
variable. Nurses’ recall is reliable over 4 weeks (Gerolamo,
2008). In this study, the clinical nurse managers were able to
support their memories by checking charts, protocols, etc., to
answer many of the questions. Additionally, recall bias could
affect when the MR-preventive factors were implemented, for
example, if patient involvement only had been implemented
for the last 3 months and not over the whole year under investigation. Thus, this factor would probably only increase the
effect on patient involvement. Nevertheless, we must consider
the possibility of recall bias with regard to other variables.
Third, three participants answered the questionnaires
twice over a 3-month interval to check the test–retest reliability (see the Data Collection section). Although three participants are too few to properly calculate reliability, the results
indicate no substantial difference in the measured constructs
between the two administrations.
Fourth, the nonresponders’ reasons for failure to reply
were reviewed, and no systematic differences were found
between those who responded and those who did not.
Reviewing the Danish National Register on coercion, we
found for the same population that 49% of responding units
were “responsible” for 52% of the MR episodes, suggesting
very small differences in MR episodes between responders
and nonresponders; however, no proper dropout analysis was
conducted. Consequently, we cannot establish whether the
high dropout rate created systematic flaws, but we believe that
the most important preventive factors and background variables were included in the study. Thus, the regression coeffi164
cients most likely can be generalized to the populations of
both countries. Transferring the results to other countries,
however, would require a thorough examination of their cultures, legislations, and other relevant factors.
Finally, when the data were reanalyzed including patients
who experienced MR more than 25 times, the result differed
only marginally. Some of the parameter estimates were
slightly higher and some slightly lower, and in Model 1,
patient involvement became significant, but the effect in
Model 3 was unchanged. Overall, exclusion of the patients
who experienced MR more than 25 times did not affect
results.
Implications for Nursing Practice and Research
Because no causal effect was established between the reduction in MR episodes and mandatory review, patient involvement, or no crowding, we cannot claim that implementation
of these potential preventive measures would reduce the
number of MR episodes. More studies are needed to investigate effective procedures to reduce the number of MR
episodes; however, because mandatory review, patient
involvement, and no crowding did not have any adverse
effects, they are recommended because they might contribute
positively to existing MR-preventive management programs.
Acknowledgments
We thank the Health Science Research Foundation in the
Capital Region of Denmark, the Mental Health Services in the
Capital Region of Denmark, and the Mental Health Centre
Sankt Hans, Copenhagen University Hospital for funding this
project.
We thank all of the clinical nurse managers of the “closed”
psychiatric units in Norway and Denmark for participating in
this project.
The authors also thank Volkert Dirk Siersma, Statistician,
PhD, the Research Unit for General Practice, Centre for
Health and Society, Copenhagen University, and the Department of Biostatistics at Copenhagen University for supervising the data analyses.
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Paper 4
Comparing the effect of non-medical mechanical restraint preventive factors
between psychiatric units in Denmark and Norway.
Comparing the effect of non-medical
mechanical restraint preventive factors
between psychiatric units in Denmark
and Norway
Nord J Psychiatry Downloaded from informahealthcare.com by Rigshospitalet on 01/23/15
For personal use only.
JESPER BAK, VIBEKE ZOFFMANN, DORTE MARIA SESTOFT,
ROGER ALMVIK, VOLKERT DIRK SIERSMA, METTE BRANDT-CHRISTENSEN
Bak J, Zoffmann V, Sestoft DM, Almvik R, Siersma VD, Brandt-Christensen M. Comparing
the effect of non-medical mechanical restraint preventive factors between psychiatric units in
Denmark and Norway. Nord J Psychiatry 2015;68:1–11.
Background: The use of mechanical restraint (MR) is controversial, and large differences
regarding the use of MR are often found among countries. In an earlier study, we observed that
MR was used twice as frequently in Denmark than Norway. Aims: To examine how presumed
MR preventive factors of non-medical origin may explain the differing number of MR episodes
between Denmark and Norway. Methods: This study is a cross-sectional survey of psychiatric
units. Linear regression was used to assess the confounding effects of the MR preventive
factors, i.e. whether a difference in the impact of these factors is evident between Denmark and
Norway. Results: Six MR preventive factors confounded [Δexp(B)⬎ 10%] the difference in MR
use between Denmark and Norway, including staff education (⫺ 51%), substitute staff (⫺ 17%),
acceptable work environment (⫺ 15%), separation of acutely disturbed patients (13%),
patient–staff ratio (⫺ 11%), and the identification of the patient’s crisis triggers (⫺ 10%).
Conclusions: These six MR preventive factors might partially explain the difference in the
frequency of MR episodes observed in the two countries, i.e. higher numbers in Denmark
than Norway. One MR preventive factor was not supported by earlier research, the identification
of the patient’s crisis triggers; therefore, more research on the mechanisms involved is needed.
Clinical implications: None of the six MR preventive factors presents any adverse effects;
therefore, units in Denmark and Norway may consider investigating the effect of implementing,
the identification of the patient’s crisis triggers, an increased number of staff per patient,
increased staff education, a better work environment and reduced use of substitute staff
in practice.
• Coercion, Mechanical restraint, Mental health, Nursing, Psychiatry.
Jesper Bak, Research Institute, Mental Health Centre Sct. Hans, Boserupvej 2, 4000 Roskilde,
Denmark, E-mail: [email protected]; Accepted 4 December 2014.
I
n Denmark and Norway, mechanical restraint (MR)
can be legally performed when psychiatric inpatients
pose a risk to themselves or others (1, 2). The procedure
is primarily performed by nursing staff, and involves the
use of leather or fibre belts to secure the patient to a
bed. MR exposes patients to potential physical risks
(3–7) and has negative psychological effects for many
patients (8–12).
A Danish review (13) identified numerous MR preventive factors based on studies that target MR prevention. No MR preventive factors found in the review
received the highest scientific recommendation grade.1
Furthermore, several of these MR preventive factors
© 2015 Informa Healthcare
might be effective only in controlled research environments.
In an earlier retrospective association study (14), we
found three MR preventive factors associated with low
numbers of MR episodes in Denmark and Norway (mandatory review, patient involvement and no crowding). In
that study, we eliminated the differences between the countries by making adjustments to make the findings more
universal. However, focusing on the differences between
the countries is important when the aim is to develop
effective MR reduction programs in Denmark and Norway.
In a comparative study on the use of coercion in 11
European countries, including Denmark and Norway
DOI: 10.3109/08039488.2014.996600
J BAK ET AL.
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For personal use only.
(15), Norway had the lowest rate of physical coercion
(MR, seclusion and physical restraint/holding) with 29
inhabitants per 100,000 experiencing physical coercion.
In comparison, Denmark had 122 episodes of MR per
100,000 inhabitants, and Norway had 87 episodes of MR
per 100,000 inhabitants in 2007 (16, 17). The same tendency was observed in the subpopulation we investigated
earlier (14); Denmark had 72 MR episodes per 100,000
inhabitants, and Norway had 42 MR episodes per
100,000 inhabitants. The lower frequency of MR episodes in Norway might indicate that more effective MR
preventive factors have been implemented in Norway
compared with Denmark or that MR preventive factors
exhibit differing effects between the countries.
Aim
To examine how presumed MR preventive factors of
non-medical origin may explain the differing number of
MR episodes between Denmark and Norway.
access to the requested information. The units were the
smallest organizational collection of beds led by a clinical nurse manager.
Time frame
The Danish questionnaire was administered between 23
December 2009 and 28 May 2010, and the collected data
pertained to 2008. The Norwegian questionnaire was
administered between 29 October 2010 and 27 January
2011, and the collected data pertained to the previous
12 months, most of which occurred in 2010.
Included participants
The study included all psychiatric hospital units in Denmark (n ⫽ 87) and Norway (n ⫽ 96) that treated adult
inpatients (18–65 years) and used MR for approximately
2 years prior to the year of investigation. MR did occur
in Norway in settings other than hospitals; however, given
that only 1.5% of recorded MR episodes in 2007 occurred
in these settings (16) and that hospitals served as the primary focus of this study, these units were not included.
Material and methods
A comparative study was conducted to investigate the
degree to which the non-medical MR preventive factors
identified in a previous review (13) were implemented in
the psychiatric units and whether the chosen MR preventive factors association with the number of MR episodes
differed between Denmark and Norway.
The following conditions must be present legally to
initiate MR according to the Danish Mental Health Act
(translated by the authors) (1):
Mechanical restraint may be used only when necessary to
prevent a patient from
1) exposing their body or health or the body or health of
others to danger,
2) pursuing or in any other way grossly molesting fellow patients, or
3) committing significant acts of vandalism.
These conditions are consistent with Norwegian legislation (translated by the authors) (2):
Restraints may be used on a patient only when absolutely
necessary to prevent him or her from damaging him or
herself or others or to prevent damage to buildings, clothing, inventory or other things.
This paper uses Bowers et al.’s (18) definition of MR:
The use of restraining straps, belts or other equipment to
restrict movement. Note that this definition refers only to
the restraint of inpatients in psychiatric hospitals.
The MR preventive factors identified by the literature
review (13) were included in an online questionnaire and
sent to the clinical nurse managers for the purpose of
quantifying whether they were implemented in the units.
These managers were chosen because they had exclusive
2
Excluded participants
The special high-security department in Denmark was
excluded due to specific legislation concerning seclusion.
Excluded outcome data
If MR was used more than 25 times on the same patient
during the investigation period, then the episodes of
MR ⬎ 25 were excluded. Chance determined the units to
which these patients were admitted, but the presence of
these patients could significantly affect the units’ MR
frequencies, distorting the results.
Data collection: the questionnaire
A questionnaire was developed based on the results from
an earlier systematic literature review that focused on
factors that might reduce the use of MR (13).
Each MR preventive factor was “translated” into questions to identify the degree to which the factor was present in the units.
Six factors were not included in the present study.
Combined intervention programmes, were omitted
because it were too complex to measure. The following
four factors were omitted because they were not considered measured appropriately by the questionnaire: treatment of substance abuse and psychosis, patients perceived
as a resource in their own treatment, pro necessitate
[p.n.]/as-needed medication guided by individual patients,
and care alliance. Lastly, music used as a diversion and
for relaxation were omitted, because it were partially covered by another factor, activity-based nursing.
Cognitive milieu therapy and patient involvement and
patient-centred care and patient involvement, were sepaNORD J PSYCHIATRY·EARLY ONLINE·2015
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PREVENTING MECHANICAL RESTRAINTS IN PSYCHIATRY
rated into three factors: cognitive milieu therapy, patientcentred care, and patient involvement. Although patient
involvement is part of cognitive milieu therapy and
patient-centred care, it might also occur by itself. Leaving, 22 separate MR preventive factors to be included in
the present study.
The questionnaire was developed by conceptualizing
and operationalizing the MR preventive factors. To
increase validity and reliability, we followed the Question Appraisal System [QAS-99 (19)] that was developed
to identify problems in questionnaires, including the
cognitive processes inherent to the question-answering
process.
The construction and pre-testing of the questionnaire
involved an eight-step appraisal of each item (QAS-99):
reading, instructions, clarity, assumption, knowledge/memory, sensitivity/bias, response categories and others.2 The
pre-test was conducted by creating a cognitive-test protocol that included probes for each item. The probes covered the aforementioned eight steps and consisted of
several types: general (e.g. How did you reach this
answer?); specific (e.g. Why do you believe MR is an
intrusive and coercive measure?); understanding/interpretation (e.g. How do you define physical activity?); safety
(e.g. How sure are you of your answer?); paraphrasing
(e.g. Can you repeat the question in your own words?);
and memory (e.g. How did you know that you had 56
MR last year?).
The pre-test consisted of cognitive interviews (20) of
four clinical nurse managers individually using concurrent probing (21), in which verbal probes were asked
immediately after a question. This protocol led to the
revision of seven questions that were subsequently pretested in a group interview.
Data collection, administration, and processing, as
well as error identification and the creation of electronic
data files (22, 23), were administered using the electronic
web-based survey system Enalyzer (2010).
The questionnaire was checked for test–retest reliability by asking three clinical nurse managers to answer the
questionnaire a second time after a 3-month interval (The
respondents were instructed not to check their previous
answers). The estimated mean correlation between all of
the first and second answers was reasonable (Kendall’s
Taub (tKen,b) ⫽ 0.75). With regard to the Norwegian portion of the study, the questionnaire was translated and
retranslated by JB and then checked by two healthcare
professionals who were familiar with the subject. A pretest was conducted to test face validity through cognitive
interviews of seven clinical nurse managers. This test led
to the revision of eight questions, mostly due to imprecise translations. Moreover, one question was added to
the questionnaire due to different staff competences: psychologists in Norway are partially responsible for their
patients’ treatment, which is not the case in Denmark.
NORD J PSYCHIATRY·EARLY ONLINE·2015
Later, the outcome variable (i.e. the number of MR
episodes) was re-examined. This procedure was necessary due to the confusing wording of a heading in the
Danish questionnaire and the lack of precise numbers
regarding the Norwegian patients who experienced MR
more than 25 times (14 answer categories instead of
the actual number were provided, which made the
exclusion imprecise). The re-examination was accomplished by contacting all of the clinical nurse managers
in Denmark and four of the clinical nurse managers in
Norway. The respondent rate was 94%, and the results
lowered the overall frequency of MR by 3.2%. A high
correlation coefficient (tKen,b ⫽ 0.89) was found between
the two answers, revealing that the confusing headline
and the categorization error did not have an important
effect.
A description of how the 22 dichotomized MR preventive factors were measured in the Supplementary
Appendix to be found online at http://informa healthcare.
com/doi/abs/10.3109/08039488.2014.996600.
Background variables
Several conditions might have affected the outcome.
These conditions included unit size, bed occupancy, type
of bed, reason for the MR, forensic provision, ethnicity
other than Danish/Norwegian and type of unit. A description of the background variables included in the study is
presented in Table 1.
Other variables, e.g. the unit’s population base, the
country’s inhabitants and patient flow, could also affect
the outcome; however, these variables were covered by
the previously mentioned covariates. Unit type and unit
size acted as proxy covariates [e.g. patient flow and population base were included in unit type; inhabitants were
included in unit size, where the number of beds per
100,000 inhabitants in each country was very similar
(Denmark ⫽ 23.96 and Norway ⫽ 22.81 beds per 100,000
inhabitants)].
A patient’s gender is most likely not associated with
MR (24, 25); thus, we did not use gender as a covariate.
Data analyses
The data analyses were conducted in five steps. First, we
analysed the difference in the frequency of MR episodes
between the countries. Second, we analysed how the factors were individually associated with the number of MR
episodes in Denmark and Norway separately. Third, we
determined whether an interaction between the MR preventive factors and the country (second order interaction,
SOI) existed. Fourth, we analysed the difference in the
prevalence of the MR predictive factors between the two
countries using Pearson’s chi-squared test (χ2). Fifth, we
analysed the confounding effects of the MR preventive
factors, i.e. the difference in the effect of the country in
3
J BAK ET AL.
Table 1. Background variables.
Number of MR
episodes per
unit in
Denmark
Background variables
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Unit size
0–9 beds
10–19 beds
More than 20 beds
Bed occupancy*
ⱕ 100% occupancy rate
⬎ 100% occupancy rate
Type of bed
Closed
Shielded or integrated
Open or other
Reason for the MR*
Self-mutilation or suicidal behaviours
Aggressive behaviours or “acting out”
Forensic provision
ⱕ 20.65% of patients with a forensic provision
⬎ 20.65% of patients with a forensic provision
Ethnicity
ⱕ 10.6% of patients with an ethnic background other than Danish/
Norwegian
⬎ 10.6% of patients with an ethnic background other than Danish/
Norwegian
Type of unit
Acute
Forensic/secure
Special/rehabilitation/long-term
Number of MR
episodes per
unit in Norway
χ2: Difference in
the prevalence of
the background
variable between
countries
Missing
n
Mean
n
Mean
P
0
2
33
8
16
51
28
14
30
3
17
23
21
0.00
1
35
8
50
22
43
3
21
20
0.08
0
6
12
25
15
50
50
7
4
36
18
15
22
0.54
2
2
41
41
10
34
47
47
4
18
0.48
0.46
3
25
15
45
47
39
8
23
10
0.03
7
24
48
27
18
0.79
16
42
16
25
6
12
25
15
50
50
7
4
36
18
15
22
0
0.05
MR, mechanical restraint.
Missing, number of missing data from units within each background variable; n, number of units in each category.
*Used as a continuous variable in further analyses.
χ2, P-value of a chi square test for the difference in the prevalence of the background variables in the units between the countries.
models with and without the corresponding MR preventive factor expressed as a percentage [Δexp(B)]; a percentage of greater than 10% was chosen to denote a
difference.
Linear regression was used to estimate the associations among the frequency of MR episodes, the countries, and the MR preventive factors. To stabilize the
variance, the outcome was logarithmically transformed.
Hence, the regression coefficients are back-transformed
[exponentiated; exp(B)] and should be interpreted multiplicatively. Because the preventive factors were dichotomized, a regression coefficient exp(B) indicates the
average number of times MR increased for units where a
factor was present compared with units where this factor
was absent (e.g. if the result was exp(B) ⫽ 0.42, it should
be interpreted as 0.42 times the average number of MR
incidents without the MR preventive factor or 58% fewer
MR episodes occur with the MR preventive factor than
without). Except in the first analysis, where the dichotomized variable was “country”, here the regression
4
coefficient exp(B), indicates the difference between the
countries in an average number of MR episodes.
All models except the fourth set of analyses (χ2-test)
were additionally adjusted for background variables.
Additionally, we adjusted for nesting of units in departments (17 departments contained two units each and
three departments contained three units each), using Generalized Estimating Equations (GEE).
To account for multiple testing, a P-value ⬍ 0.01 was
chosen to indicate significance. All analyses were performed using IBM SPSS Statistics for Windows, Version
19.0 (Released 2010; IBM Corp., Armonk, NY).
Approval and ethics
Questionnaires, such as the one included in the present
study, do not require approval from the scientific ethical
committee system in Denmark or Norway when the
respondents are able to provide informed consent or when
sensitive information is not collected. The Danish Data
Protection Agency (Journal number: 2007-58-0015, PSVNORD J PSYCHIATRY·EARLY ONLINE·2015
PREVENTING MECHANICAL RESTRAINTS IN PSYCHIATRY
Denmark
(n=87)
Norway
(n=96)
Excluded: special
high-security
forensic units
(n=3)
Non-responders/
Refused/Missing
data (n=41)
Non-responders/
Refused/Missing
data (n=49)
Included
(n=43, response rate 49%)
Included
(n=47, response rate 49%)
Participants from Denmark and Norway
(n=90, response rate 49%)
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Fig. 1. Flowchart of the units participating in the survey.
2009-13) approved the data collection, and we received
permission from the Danish Health and Medicines
Authorities and the Danish Psychiatric Central Research
Register to use the register data on the frequency of MR
in Denmark (26).
This study followed the Ethical Guidelines for Nursing Research in the Nordic Countries (Northern Nurse
Federation, 2003) and the Recommendations on Legal
Protection of Persons Suffering from Mental Disorders
Especially Those Placed as Involuntary Patients (27).
Results
A flowchart of the participating units can be found in
Figure 1, and the annual number of MR episodes can be
found in Table 2.
A difference in MR episodes was observed between
the countries in a model that included the background
variables [exp(B) ⫽ 1.92, P ⫽ 0.01] (Fig. 1, Table 2).
Table 3 indicates that a single MR preventive factor,
staff education [exp(B) ⫽ 0.34, P ⫽ 0.00], was significantly associated with a lower frequency of MR episodes
in Denmark. In Norway, three MR preventive factors
were significantly associated with a higher frequency of
MR episodes: cognitive milieu therapy [exp(B) ⫽ 7.46,
P ⫽ 0.00], patient-centred care [exp(B) ⫽ 5.01, P ⫽ 0.00]
and alarm systems [exp(B) ⫽ 3.72, P ⫽ 0.00]. Notably,
for cognitive milieu therapy and patient-centred care, the
confidence intervals were large, which makes the interpretation less precise.
We identified three incidents of interaction among the
MR preventive factor, the countries and the frequency of
MR episodes: cognitive milieu therapy (SOI, P ⫽ 0.00),
patient-centred care (SOI, P ⫽ 0.01) and alarm systems
(SOI, P ⫽ 0.00). Each of these factors exhibited a positive effect in Denmark [exp(B): 0.36, 0.41, and 0.18]
and a negative effect in Norway [exp(B): 7.46, 5.01,
and 3.72].
Six MR preventive factors were significantly different
between the two countries: the identification of a
patient’s crisis triggers (χ2, P ⫽ 0.01), patient–staff ratio
(χ2, P ⫽ 0.00), staff education (χ2, P ⫽ 0.00), acceptable
work environment (χ2, P ⫽ 0.01), substitute staff (χ2,
P ⫽ 0.00) and separation of acutely disturbed patients
(χ2, P ⫽ 0.00).
Lastly, we identified six MR preventive factors with
confounding effects, i.e. the MR preventive factor acted
as a confounder [Δexp(B)⬎ 10%]: identification of the
patients’ crisis triggers [Δexp(B) ⫽ ⫺ 10%], patient–staff
ratio [Δexp(B) ⫽ ⫺ 11%], staff education [Δexp(B) ⫽ ⫺ 51%],
acceptable work environment [Δexp(B) ⫽ ⫺ 15%], substitute
staff [Δexp(B) ⫽ ⫺ 17%] and separation of acutely disturbed
patients [Δexp(B) ⫽ 13%]. In both countries, the following
MR preventive factors was associated with lower numbers
of MR episodes: identification of patients’ crisis triggers
(Denmark, exp(B) ⫽ 0.65; Norway, exp(B) ⫽ 0.75), a higher
patient–staff ratio (Denmark, exp(B) ⫽ 0.96; Norway,
exp(B) ⫽ 0.62), higher levels of staff education (Denmark,
exp(B) ⫽ 0.34; Norway, exp(B) ⫽ 0.76), better work environment (Denmark, exp(B) ⫽ 0.52; Norway, exp(B) ⫽ 0.55),
reduced use of substitute staff (Denmark, exp(B) ⫽ 0.59;
Table 2. Annual number of mechanical restraint (MR) episodes.
Denmark and
Norway
(n ⫽ 90)
Annual number of MR episodes
Mean annual number of MR episodes per unit
Mean annual number of MR episodes per bed
Mean annual number of MR episodes per 100,000 inhabitants
Denmark
(n ⫽ 43)
No.
Norway
(n ⫽ 47)
No.
Range
Range
No.
Range
2927
32.5
2.5
58
–
1938
–
0–254
45.1 0–254
0–15.9
3.2 0–15.9
–
72
–
989
21.0
2.0
42
–
0–74
0–7.1
–
No., the number of MR episodes. Nine units accounted for 451 of the excluded MR episodes (⬎ 25 per person),
thereby leaving 1938 episodes in Denmark and 989 in Norway for analysis. The number of MR episodes per
100,000 inhabitants in this sub-sample is estimated from the number of MR episodes, the response percentages
and the number of inhabitants the actual year.
NORD J PSYCHIATRY·EARLY ONLINE·2015
5
6
21
19
49
10
5
7
84
72
78
38
14
51
19
27
7
20
55
50
9
8
20
4
2
3
36
28
32
15
6
19
8
11
3
8
23
21
1.05
0.89
1.56
2.85
0.38
1.26
1.30
0.96
0.34
0.81
0.79
0.61
0.78
0.52
0.59
0.59
1.09
0.18
0.36
0.66
0.41
0.65
exp(B)
[0.46–2.40]
[0.42–1.87]
[0.85–2.85]
[1.28–6.36]
[0.15–0.97]
[0.65–2.46]
[0.56–2.99]
[0.45–2.06]
[0.17–0.66]
[0.45–1.44]
[0.46–1.36]
[0.29–1.29]
[0.34–1.79]
[0.22–1.25]
[0.31–1.13]
[0.32–1.10]
[0.47–2.54]
[0.03–1.17]
[0.11–1.16]
[0.26–1.71]
[0.12–1.38]
[0.38–1.10]
95% Cis of
exp(B)
0.90
0.75
0.15
0.47
0.40
0.20
0.56
0.14
0.11
0.10
0.84
0.07
0.01
0.04
0.49
0.54
0.91
0.00*
0.09
0.40
0.15
0.11
P
38
29
17
17
7
21
13
25
43
44
24
34
22
17
20
33
17
5
1
37
4
40
No.
83
63
36
37
15
48
28
53
93
98
65
85
54
40
59
73
39
11
3
86
10
93
[0.60–3.26]
[0.21–1.37]
[0.39–2.01]
[0.53–3.06]
[0.32–1.19]
[0.28–2.04]
[0.14–2.19]
[1.07–3.89]
[0.49–7.44]
[0.25–1.88]
[0.30–1.03]
[0.27–1.14]
[0.25–1.18]
[0.30–1.63]
[2.16–6.41]
[2.94–18.89]
[0.27–1.31]
[2.03–12.36]
[0.26–2.17]
95% CI of
exp(B)
1.94 [0.92–4.09]
1.03 [0.53–2.04]
1.03 [0.51–2.10]
1.39
0.53
0.88
1.28
0.62
0.76
0.56
2.04
1.92
0.69
0.55
0.55
0.54
0.70
3.72
7.46
0.60
5.01
0.75
% exp(B)
Norway
0.08
0.92
0.93
0.28
0.63
0.43
0.13
0.97
0.22
0.75
0.56
0.05
0.84
0.02
0.80
0.53
0.93
0.22
0.33
0.65
0.00*
0.00*
0.80
0.00*
0.67
0.00*
0.20
0.00*
0.59
0.45
0.19
0.76
0.59
0.15
0.59
0.41
0.03
0.35
0.47
0.06
0.11
0.12
0.41
0.00*
P
P
0
13†
0.00*
3
7
⫺1
0
3
⫺ 11†
⫺ 51†
⫺1
⫺3
⫺1
⫺6
⫺ 15†
6
⫺ 17†
⫺1
4
6
⫺2
3
⫺ 10†
%
0.43
0.08
0.53
0.00*
0.25
0.50
0.02
0.52
0.42
0.14
0.01*
0.11
0.60
0.92
0.03
0.00*
0.00*
0.09
0.53
0.72
0.01*
P
Δ exp(B)
Difference in the
effect of country
No., the number of units where the factor was present; %, the percentage of units where the factor was present; exp(B), the parameter estimate. The outcome variable (i.e. the number of MR episodes)
was log-transformed. Hence, the exp(B) should be interpreted multiplicatively (e.g. in Denmark, cognitive milieu therapy results in 0.36 times the average number of MR incidents without cognitive milieu
therapy (or 64% fewer MR episodes occur with cognitive milieu therapy than without). 95% CI of exp(B), 95% Wald confidence interval for exp(B); P, P-value; SOI, second order interaction, P-value of
a test for the interaction between the MR preventive factor and the country, i.e. whether the effect of the MR preventive factor differs between the countries; χ2, P-value of a chi square test for the difference
in the prevalence of the MR preventive factor in the units between the countries; Δ exp(B), Differences in the effect of the country in models with and without the corresponding MR factor (confounding
effect of the MR preventive factor) expressed as a percentage; negative Δ exp(B) values should be interpreted as a MR preventive factor that minimises the difference between the countries. In the estimation
of exp(B), SOI, and Δ exp(B), we used linear regression and adjusted for the following background variables: unit size, bed occupancy, type of bed, reason for the MR, forensic provision, ethnicity and
type of unit. Additionally, the nesting of units in departments was adjusted using Generalized Estimating Equations (GEE) techniques. *P ⬍ 0.01. †Δexp(B)⬎⫾ 10%.
13
81
13
69
5
34
5
29
Cognitive milieu therapy vs. no cognitive milieu therapy
Patient involvement vs. no patient involvement
Patient-centred care vs. no patient-centred care
Identification of the patient’s crisis triggers vs. no
identification
Risk assessment vs. almost none or no risk assessment
Mandatory review vs. no mandatory review
Staff training (⬎ 50% vs. less)
Positive staff attitudes vs. less positive
Patient–staff ratio (⬎ 3 staff per patient vs. less)
Staff education (ⱕ 3.5 years vs. less)
Staff experience (⬎ 5 years vs. less)
Debriefing, defusing vs. none
Positive patient responses to rules vs. negative responses
Activity-based nursing vs. no activity-based nursing
Acceptable work environment vs. poor work environment
No crowding vs. crowding
Substitute staff (⬍ 50 vs. more)
Staff opposition to MR (many vs. some)
Alarm systems (many and well-trained responses vs. less
well-trained responses)
Communication (all staff possess communicative skills vs.
less than all)
Well-maintained, clean and tidy surroundings (always vs.
seldom)
Separation of acutely disturbed patients vs. no separation
%
No.
MR preventive factors
Denmark
SOI: Interaction
between the MR
preventive factor
and the country
χ2: Difference
in the
prevalence
of the MR
predictive f
actor between
countries
Table 3. Differences in the effects of potential mechanical restraint (MR) preventive factors on the annual number of MR episodes in Denmark and Norway.
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NORD J PSYCHIATRY·EARLY ONLINE·2015
PREVENTING MECHANICAL RESTRAINTS IN PSYCHIATRY
Norway, exp(B) ⫽ 0.54), except more separation of acutely
disturbed patients, which was associated with increased MR
episodes (Denmark, exp(B) ⫽ 1.05; Norway, exp(B) ⫽ 1.94).
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Discussion
Three potential MR preventive factors displayed very different effects in the two countries, which was demonstrated by significant interactions among the MR
preventive factor, the countries and the frequency of MR
episodes. These preventative factors included cognitive
milieu therapy (SOI, P ⫽ 0.00), patient-centred care (SOI,
P ⫽ 0.01) and alarm systems (SOI, P ⫽ 0.00). None of
the factors had a significant difference in prevalence (χ2,
P ⫽ 0.09, 0.72, and 0.50). Therefore, it was difficult to
interpret the differences in the effect based on the country [Δexp(B)] due to the interaction. It was also difficult
to determine why these factors exhibited a different effect
in the two countries. One explanation of why cognitive
milieu therapy and patient-centred care were effective in
Denmark could be that these two factors were well
described as methods and included a treatment philosophy in Denmark. Therefore, in Denmark, these descriptions of care and treatment actually covered phenomena
such as patient involvement and cooperation; this was, to
our knowledge, not the case in Norway in 2010. Another
potential explanation is that the limited number of units
in Norway that had implemented the three MR preventive factors could be special units with fewer MR episodes. Although the three MR preventive factors were
significantly associated with an increased number of MR
episodes in Norway, we would not recommend that Norway implement less of these three factors given the small
number of units that implemented the factors. Further
research is needed to explore the different effects of these
three MR preventive factors.
Six MR preventive factors exhibited a significant difference between the countries with regard to the frequency of MR episodes [Δexp(B)].
First, identification of a patient’s crisis triggers: units
wherein the initial nurse evaluation of at-risk patients
always contained a written evaluation of aggressive, selfmutilating or suicidal behaviours (e.g. crisis triggers,
unique calming techniques, and coping strategies) vs.
units where the initial evaluation only occasionally or
never contained a written evaluation. This factor explains
a large [Δexp(B) ⫽ ⫺ 10%] portion of the difference in
MR episodes between the countries. The identification of
a patient’s crisis triggers was supported by earlier
research. In a well-designed before and after study, Jonikas et al. (28) observed a significant decrease (between
49% and 99%) in physical restraint episodes after
patients were interviewed to determine their crisis triggers and personal crisis management strategies. In a reasonably designed cluster randomized controlled trial
NORD J PSYCHIATRY·EARLY ONLINE·2015
(RCT), Putkonen et al. (29) reported the same tendency,
where seclusion and restraint time decreased by 51%
after implementing six core strategies to prevent seclusion and restraint. In both studies, the effect was attributed to variables other than the patients’ crisis triggers.
In a one-way case-crossover designed study, Fluttert
et al. (30) reported that implementing the early recognition method (ERM) decreased the number of seclusions
by 54%. The ERM is a technique for patients and staff
to work systematically with the patients’ triggers (early
warning signs), crisis intervention and coping strategies;
this is the same identification procedure we asked the
clinical nurse managers about in the questionnaire. Overall, the earlier research supports the finding that, identification of a patient’s crisis triggers, is part of explaining
the difference in MR use between the two countries. The
mechanism involved in this process is probably that
patients and staff earlier recognize sign of a forthcoming
crisis, and together develop counteractions to avoid escalation of the crisis, thereby reducing the risk of a MR
episode. Early prevention could constitute one of the
most effective strategies to reduce MR episodes.
Second, patient–staff ratio: units in which the staffto-patient ratio was higher than or equal to three-to-one
on average vs. those units where this ratio was lower
than three-to-one. In Denmark, the effect was small, possibly due to the small number of units where the staff-topatient ratio was lower than three-to-one on average. The
factor explains a large [Δexp(B) ⫽ ⫺ 11%] portion of the
difference in MR episodes between the countries. The
effects of the staff-to-patient ratio were partially supported by earlier research. Smith et al. (31) found a 66%
decrease in restraint episodes. However, because several
factors contributed to the effect, it is unclear what portion of the MR reduction was attributable to the 50%
increase in staffing. Janssen et al. (32) found that seclusion was used more commonly when the number of
patients per staff was greater in long-term wards. Donat
(33) reported a significant association between increased
staffing levels and decreased MR and seclusion numbers.
However, Owen et al. (34) noted that the relative risk of
violence increased with more nursing staff. In addition,
Bowers et al. (35) reported that increased levels of
aggressive incidents were associated with increased staffing. Nonetheless, both studies with opposite outcomes did
not precisely target MR or seclusion but instead targeted
violence and aggression; the results could be influenced
by staff employment policies, wherein staffing levels are
increased in units with more aggressive incidents. Our
study most likely eliminated this problem by introducing
“type of unit” and “type of bed” as confounders. Overall,
the earlier research specific dealing with the same conditions does support the finding that, the staff to patient
ratio, is part of explaining the difference in MR use
between the two countries. The mechanisms involved in
7
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J BAK ET AL.
higher staffing levels could be that the staff would be
more able to observe, interact and corporate with the
patients, probably reduce the number of stressed staff,
thereby calming the environment, having more personal
resources to positive reinforcement, support, and communication, hopefully creating a more empowering and
recovery orientated environment for the patients.
Third, staff education: units wherein the staff received
basic training for at least 31/2 years vs. units where the
staff had less than 31/2 years of training. The factor
explains a large portion [Δexp(B) ⫽ ⫺ 51%] of the difference in MR episodes between the countries. Staff education was supported by earlier research. Janssen et al. (32)
reported that seclusion was used more commonly in units
with less educated staff in the long-term wards. Gim
et al. (36) found a significant difference between psychiatric trained and non-psychiatric trained staff in identifying and managing precipitants of violence. In a large
20-year analysis of 1,565 mental health workers, Flannery et al. (37) found that staff who were victims of
patients’ aggressions were less formally educated and
less trained. None of the studies was an RCT, but otherwise well designed, so it is reasonable to deduce, that
earlier research supports the finding that, staff education,
is part of explaining the difference in MR use between
the two countries. Higher basic education among staff is
probably leaving the staff with higher analytic and action
competences, even in crisis situations, thereby reducing
the number of MR episodes.
Fourth, acceptable work environment: units where a
workplace environment assessment was present, no or
only insignificant physical or mental work-environment
problems existed, and the overall work environment
was evaluated as acceptable vs. units where the
workplace environment was not assessed, more workenvironment problems existed, and the overall work
environment was evaluated as poor. This factor explains
a large [Δexp(B) ⫽ ⫺ 15%] portion of the differences in
MR episodes between the countries. An acceptable
work environment is somewhat complex because the
work environment is a mix of leadership, degree of
order, organization, staffing, training, crowding, etc.
De Benedictis et al. (38) reported that several organizational factors, e.g. team climate, staff perception of
aggression and interaction of team-members, were associated with increased use of seclusion and restraint.
Hanrahan et al. (39) observed a relationship between
psychiatric nurses’ work environments and inpatients’
environments. van der Schaff et al. (40) reported a
number of building design features that had an effect
on seclusion and restraint. Virtanen et al. (41) indicated
that patient overcrowding was associated with violent
assaults towards employees. Huckshorn (42) found that
leaders played a critical role in reducing seclusion
and restraint. Camerino et al. (43) found a significant
8
association between work-related factors and some types
of violence. Some of the other examined factors are
also part of the overall work environment, such as staff
training, staff/patient ratio, etc. Overall, the research
that supports the association between MR and work
environment includes many parts of a healthy work
environment, and it supports the finding that the
work environment partly explains the difference in MR
use between the two countries Whatever part of the
environment that creates a positive work environment,
the wellbeing of the staff is most certainly affecting the
wellbeing of the patients, so when staff experiences a
more positive work environment the patient probably
experience a more positive environment.
Fifth, substitute staff: units in which substitute staff
was used less than 50 times (8-h shifts) over the year
vs. units where these employees were used greater than
or equal to 50 times. The factor explains a large
[Δexp(B) ⫽ ⫺ 17%] portion of the difference in MR episodes between the countries. The effects of substitute
staff were supported by earlier research. Bonner et al.
(8) found that both patients and staff discriminated
between permanent and regular staff. Bowers et al. (44)
reported that adverse incidents were more likely to occur
during weeks where regular staff was absent. In another
study, Bowers et al. (35) noted that increased levels of
aggression were associated with an increased use of bank
and agency staff. None of the studies was an RCT, but
all the studies indicate similar results, supporting less
use of substitute staff. The reason for this finding could
be that substitute staff lacks knowledge of the unit structures, processes and patients, thereby creating insecurity
and disturbances in the everyday life of the unit among
some of the most vulnerable patients. This could be a
stressing factor for the patients creating more aggressive
or self-destructive behaviour—hence, more MR episodes.
Sixth, one factor, separation of acutely disturbed
patients, had different results: units that were able to
separate acutely disturbed patients from other patients vs.
units that were unable to separate patients. The factor
explains a large [Δexp(B) ⫽ 13%] portion of the difference in MR episodes between the countries. This negative association was not supported by earlier research; in
fact, the opposite result was indicated. In a qualitative
content analysis study, Meehan et al. (45) noted that
patients proposed that the separation of acutely disturbed
patients would reduce the number of aggressive incidents. Overall, this result is not supported by earlier
research. Therefore, more research is needed to explore
the mechanisms involved in placing one or few patients
in a separate and isolated part of the unit.
Limitations
Several limitations must be considered when examining
the results.
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PREVENTING MECHANICAL RESTRAINTS IN PSYCHIATRY
First, some confounding covariates might be missing
from the analyses. We believe that we included the most
important covariates or covered the effects of others by
proxy (46), e.g. patients who experience MR could be
more aggressive or self-mutilating in one of the countries—hence, acting as a confounder. However, one earlier study that assessed aggressive behaviour (47) did not
report large differences between Denmark and Norway.
Additionally, some of the covariates (number of forensic
patients, type of bed and the reason for the MR) could
eliminate portions of the difference. Therefore, it is not
likely that the potential differences in aggressive or selfmutilating patients would influence the results.
Second, recall bias is possible, especially for the
Danish data; the clinical nurse manager had to recall all
MR preventive factors as well as the conditions and
number of MR episodes from 2 years ago. The outcome
variable (i.e. the number of MR episodes) were validated
or re-examined, and this did not reveal significant recall
bias with regard to the outcome variable. Additionally,
recall bias could affect the results if the MR preventive
factors had only been implemented for a portion of the
year. Thus, this recall bias would most likely only
increase the effect on patient involvement. Nevertheless,
we must consider the possibility of recall bias with
regard to some variables.
Third, three participants answered the questionnaires
twice during a 3-month interval to check the test–retest
reliability. Although three participants are insufficient to
calculate reliability properly, the results indicate no substantial difference in the measured constructs between
the two administrations.
Fourth, selection bias—the non-responders’ reasons
for failure to reply were reviewed, and no systematic
differences were observed between responders and nonresponders. Reviewing the Danish National Register on
coercion, we found that 49% of responding units were
“responsible” for 52% of the MR episodes in the same
population, suggesting minimal differences in MR episodes between responders and non-responders; however,
no proper drop-out analysis was conducted. Thus, the
results most likely can be generalized to the population
of both countries. Transferring the results to other countries, however, would require a thorough examination of
their cultures, legislation and other relevant factors.
Finally, when data were reanalysed to include patients
who experienced MR more than 25 times, the results
changed only marginally. Therefore, the exclusion of the
patients who experienced MR more than 25 times did
not affect results.
MR, but it is important to acknowledge that this type of
comparative research does not allow for cause–effect
conclusions. Thus, we cannot claim that the implementation of these potential preventive measures in Denmark
and Norway would reduce the number of MR episodes.
More high-quality studies are needed to investigate the
identification of a patient’s crisis triggers, an increased
number of staff per patient, increased staff education,
better work environment, reduced use of substitute staff,
and separation of acutely disturbed patients.
Notes
1. The review was a a systematic review combining qualitative and quantitative research, so the highest recommendation grade could be: qualitative; at least one
high-quality meta-synthesis, systematic review, or metasummary, or a body of high-quality evidence, or quantitative; at least one meta-analysis, systematic review or
one or a body of high-quality RCT.
2. STEP 1: READING: Determine if it is difficult for the
interviewers to read the question uniformly to all
respondents. STEP 2: INSTRUCTIONS: Look for
problems with any introductions, instructions or explanations from the respondent’s point of view. STEP 3:
CLARITY: Identify problems related to communicating the intent or meaning of the question to the respondent. STEP 4: ASSUMPTIONS: Determine whether
there are problems with assumptions or the underlying
logic. STEP 5: KNOWLEDGE/MEMORY: Check
whether respondents are likely to not know or have
trouble remembering information. STEP 6: SENSITIVITY/BIAS: Assess questions for sensitive nature or
wording, and for bias. STEP 7: RESPONSE CATEGORIES: Assess the adequacy of the range of responses to
be recorded. STEP 8: OTHER: Look for problems not
identified in Steps 1–7 (19).
Acknowledgements—We thank the Health Science Research Foundation
in the Capital Region of Denmark, the Mental Health Services in the
Capital Region of Denmark, and the Mental Health Centre Sct. Hans,
Copenhagen University Hospital for funding this project. We thank all
of the clinical nurse managers of the “closed” psychiatric units in
Norway and Denmark for participating in this project.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content
and writing of the paper.
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Conclusion
The comparison of these MR preventive factors may
contribute to better understanding of the phenomenon of
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PREVENTING MECHANICAL RESTRAINTS IN PSYCHIATRY
Jesper Bak, R.N., S.D., M.P.H., Ph.D. student, Head nurse, Mental
Health Centre Sct. Hans, Roskilde, Denmark. E-mail: Jesper.Bak@
regionh.dk.
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and Children’s Health, Juliane Marie Centre, Copenhagen University
Hospital, Rigshospitalet, Copenhagen, Denmark. E-mail: vibeke.
[email protected].
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Justice, Clinic of Forensic Psychiatry, Copenhagen, Denmark,
E-mail: [email protected].
Roger Almvik, R.N., R.M.N., D.Phil., Research Director, St. Olavs
University Hospital, Forensic Department Bröset, Centre for Research &
Education in Forensic Psychiatry, Norway. E-mail: [email protected].
Volkert Dirk Siersma, Ph.D., Statistician, The Research Unit for
General Practice and Section of General Practice, Department of
Public Health, University of Copenhagen, Copenhagen, Denmark,
E-mail: [email protected].
Mette Brandt-Christensen, M.D., Ph.D., Head of Department, Forensic
Psychiatry, Mental Health Centre Glostrup, Copenhagen University
Hospital, Denmark, E-mail: [email protected].
Supplementary material available online
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Appendix: A description of mechanical restraint (MR)
preventive factor measurements
NORD J PSYCHIATRY·EARLY ONLINE·2015
11
Corrigendum (private)
Correction in the abstract:
Conclusions: These six MR preventive factors might partially explain the difference in the
frequency of MR episodes observed in the two countries, i.e. higher numbers in Denmark than
Norway. One MR preventive factor was not supported by earlier research, the identification of
the patient’s crisis triggers; therefore, more research on the mechanisms involved is needed.
Should be corrected to:
Conclusions: These six MR preventive factors might partially explain the difference in the
frequency of MR episodes observed in the two countries, i.e. higher numbers in Denmark than
Norway. One MR preventive factor was not supported by earlier research, separation of acutely
disturbed patients; therefore, more research on the mechanisms involved is needed.
Correction on page seven:
Second, patient-staff ratio: units in which the staff-to-patient ratio was higher than or equal to
three-to-one on average vs. those units where this ratio was lower than three-to-one. In
Denmark, the effect was small, possibly due to the small number of units where the staff-topatient ratio was lower than three-to-one on average.
Should be corrected to:
Second, patient-staff ratio: units in which the staff-to-patient ratio was higher than or equal to
three-to-one on average vs. those units where this ratio was lower than three-to-one. In
Denmark, the effect was small, possibly due to the small number of units where the staff-topatient ratio was higher than three-to-one on average.
Supplementary material for Bak J, et al., Comparing the effect of non-medical mechanical restraint preventive
factors between psychiatric units in Denmark and Norway, Nordic Journal of Psychiatry, 2015; doi: 10.3109/
08039488.2014.996600.
Supplementary Appendix: A description of mechanical restraint (MR) preventive factor measurements.
MR preventive factors
Cognitive milieu therapy vs. no cognitive milieu
therapy
Patient involvement vs. no patient involvement
Patient-centred care vs. no patient-centred care
Identification of the patient´s crisis triggers vs. no
identification
Risk assessment vs. almost none or no risk
assessment
Mandatory review vs. no mandatory review
Staff training (⬎ 50% vs. less)
Positive staff attitudes vs. less positive
Patient-staff ratio (⬎ 3 staff per patient vs. fewer)
Staff education (ⱖ 3.5 years vs. fewer)
Staff experience (⬎ 5 years vs. fewer)
Debriefing and defusing vs. none
Positive patient responses to rules vs. negative
responses
Activity-based nursing vs. no activity-based nursing
Acceptable work environment vs. poor work
environment
No crowding vs. crowding
Substitute staff (⬍ 50 vs. more)
Staff opposition to MR (many vs. some)
Alarm systems (numerous well trained responses vs.
less well trained responses)
Communication (all staff possess communicative
skills vs. less than all)
Well maintained, clean and tidy surroundings
(always vs. seldom)
Separation of acutely disturbed patients vs. no
separation
NORD J PSYCHIATRY·EARLY ONLINE·2015
Measurement description
The clinical nurse manager described the care in his or her unit as “cognitive behaviour
therapy” or “cognitive milieu therapy”, and the staff had participated in 40 h of training or
more in this care method—The care method was not described.
One of the following factors was present: the patients participated in ward rounds/
conferences or the patients influenced the rules imposed by the unit or influenced what
was written in the nurse’s journal—Patients did not participate in these areas.
The clinical nurse manger described the care in his or her unit using the words “individual”,
“cooperative” or “patient-centred”, and the staff participated in 40 h of training or more in
this care method—These words were not used to describe this care method.
The initial nurse evaluation of at-risk patients always contained a written evaluation of
aggressive, self-mutilating or suicidal behaviours (e.g. crisis triggers, unique calming
techniques and coping strategies)—The initial evaluation only occasionally or never
contained a written evaluation.
The risk of developing aggressive/violent or self-mutilating/suicidal behaviours was always
or almost always systematically evaluated and documented, and care actions were
initiated—These behaviours were only occasionally or never evaluated and documented.
An audit, review or similar systematic follow-up evaluation was conducted after all MR
episodes—The evaluation was only conducted after some or none of the MR episodes.
An average of 50% or more of the staff participated in training regarding de-escalation,
avoiding physical attacks, careful restraining techniques, legislation, MR predictors/
antecedents and suicide prevention—Less than 50% of the staff experienced such training.
All staff directed their attention towards the patient and possessed communicative skills,
optimism and empathy—Not all of the staff possessed these skills.
The staff-to-patient ratio was higher than or equal to three-to-one on average—This ratio
was lower than three-to-one on average.
The staff received basic training for at least 3½ years—The staff had less than 3½ years of
training.
The staff had an average of more than 5 years of experience in the psychiatric speciality was
more than 5 years on average—Staff experience was 5 years or fewer.
Follow-up evaluations were initiated after each MR episode for debriefing, defusing or other
crisis interventions—No follow-up was initiated.
The patients reacted positively to the rules, and limit-setting was motivational—The opposite
occurred.
Individual patient-activity plans were devised, and the patients participated in many or
several physical or other types of activities—The patients had no activity plans, and they
participated in few or no physical or other activities.
The unit had the following features: a workplace environment assessment was present, no or
only insignificant physical or mental work-environment problems existed, and the overall
work environment was evaluated as acceptable—The workplace environment was not
assessed, more work-environment problems existed and the overall work environment was
evaluated as poor.
Two of the following three factors were evident for no crowding: only one bed in a patient’s
room, more than 25 m2 of all day-accessible space per patient and the perception of no
crowding—Only one or none of these factors was evident.
Substitute staff was used less than 50 times (8-h shifts) over the year—These employees
were used greater than or equal to 50 times.
All staff had the attitude that “MR should be initiated rarely to protect the lives of the
patient and others”—Not all staff had this attitude.
More than three night-shift staff members responded to an alarm call, and they were all
trained in this task—Not all of the night-shift staff members were trained, or they were
trained but failed to respond.
All staff had general communicative skills or special skills with regard to communicative
de-escalation—Less than all the staff had these skills.
The unit was perceived as well maintained, clean and tidy—The perceptions were otherwise.
The unit was able to separate acutely disturbed patients from other patients—The unit was
unable to do so.
1