Paper
Paul Doedens, RNa Jolanda Maaskant, RN MScb
a. Department of Psychiatry, Academic Medical Centre, The Netherlands
b. Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Medical Faculty, Academic Medical Centre and University of Amsterdam, The Netherlands
Keywords: coercion nursing, aggression, seclusion, clinical psychiatry
Abstract
Background
Seclusion is an intervention widely used in Dutch mental health care. The intervention can be effective in acute situations to avert (further) aggression or self-harm. However, seclusion is also a controversial intervention that may not have any positive effect with regard to symptom improvement. In general patients report negative effects after being secluded e.g. anxiety and having had a traumatic experience.
The main reason for seclusion is not manageable aggressive behaviour of a patient. Earlier studies reported several risk factors that may contribute to seclusion, regarding patients’ characteristics, but also with regard to staff characteristics, working protocols and unit characteristics. Because of unequivocally results there is the need for a longitudinal prospective study to examine staff- and unit determinants in association with seclusion.
Aims
The objective of this study is to determine which nursing staff and unit characteristics are associated with seclusion following aggression in hospitalized adult psychiatric patients. We hope to create a predictive model to estimate the risk of seclusion on an acute psychiatric ward.
Methods
We will conduct a prospective observational study on a closed psychiatric ward of an academic hospital.
Patients are aged 18 – 65 years and are admitted when their psychiatric condition leads to an immediate threat to the patient themselves or their surroundings.
All nurses on the ward are all qualified nurses and registered in the Dutch registration of healthcare professionals. They are trained every six months in techniques of verbal de-escalation and safe physical restraint. For both nurses and the patients baseline characteristics are monitored. Every shift (day, evening, night) data are gathered on the patients, nurses and unit. Data are retrieved from the electronic patient chart, including information of the Brøset Violence Checklist. Furthermore, the exchange of information among nurses is measured using the Grid instrument. Data will be analysed using multilevel regression analysis. Data will be collected for a period of 2 years, which started January 2013.
Results
The primary endpoint in our study is the incidence of seclusion. As a secondary endpoint, the duration of the seclusion is measured. These endpoints are measured using the Argus registration system and will be linked to predictors of seclusion, with special focus on the nursing staff- and unit determinants.
Introduction
Seclusion is an intervention widely used in Dutch mental health care (1). In 2008 11% of the patients admitted to psychiatric hospitals where secluded during the period of time of their admission (1). Although international comparison is difficult, due to a great variety in coercive measures, it is estimated the Netherlands has one of the highest numbers of seclusions in Europe (2). The main reason to decide for seclusion is the result of a patient being aggressive, against staff, fellow patients or goods. The aggressive behaviour causes serious safety hazards in the hospital, creating an unsafe environment for other patients and healthcare professionals. Violent situations are probably well known to all working in the field of psychiatry in which patients or personnel were endangered or even hurt by aggressive patients. These
situations justify the use of seclusion (3). But seclusion is a controversial intervention that has no proven therapeutic effect (4). Moreover, patients report negative effects after being secluded e.g. they feel extreme anxiety, anger, and experience feelings of being abandoned (5). Seclusion seems to be a traumatic experience for patients and do not contribute to their recovery in the long run. Therefore, in 2004 the Dutch Ministry of Health, Welfare and Sports ordered that the Dutch mental health care seclusion rates should decrease by at least 10% each year (6). In 2010, however this goal was not achieved; the Health Care Inspectorate reported only a 5,5% decrease (7).
Several studies reported risk factors that may contribute to seclusion in mental health care. Young, male patients, especially when they are diagnosed with schizophrenia or bipolar disorder are at higher risk of being secluded during an admission (8). But also characteristics of the psychiatrists and nurses as well as the environment are believed to influence the seclusion rate.
However, the results are unequivocal and most of these studies were performed retrospectively and had several methodological limitations. For example, Nijman et al (1994) found no significant associations between staff factors and seclusion on a closed psychiatric ward (9). Vollema et al (2012) found significant associations between seclusion and the subjective feelings of safety among nurses (OR = 1,773, p = 0,005) (4). Janssen et al (2007) found male-female staff ratio and variability in team’s work experience significantly associated with seclusion rates (both variables p < 0,001) (10). The question remains whether nursing staff factors and unit characteristics may influence the risk of seclusion following aggression on an acute psychiatric ward, a question that should be answered in robust, longitudinal prospective studies (4).
We therefore designed this study to determine which nursing staff and unit characteristics are associated with seclusion following aggression in hospitalized adult psychiatric patients. By answering this question we hope to identify predictive factors from which we can estimate the risk of seclusion on an acute psychiatric ward. This insight may contribute to the development of specific interventions to prevent seclusion and therewith improve the safety of the psychiatric patients and the healthcare professionals.
Method
Design
We will conduct a prospective observational study on a closed psychiatric ward of an academic hospital.
The endpoint of our study is seclusion. Seclusion is defined in the Netherlands as the restraint of a patient for care and treatment in a designated seclusion room that is approved by the government (an empty room containing only a mattress and a blanket) (4). Whether the patient resists to the seclusion or not is not an objective of our study. Short separations of patients in a so-called ‘safe room’ at the ward are not being investigated in this study.
The Medical Ethics Review Board of the Academic Medical Centre reviewed our study protocol and decided that ethical approval was not required according to the Dutch Medical Ethics Law. Informed consent of individual participants was not necessary because of the minimal additional impact on the integrity of our study participants, as routine care is monitored and no extra interventions are employed.
Setting & participants
The study is performed at the Academic Medical Centre in Amsterdam, the Netherlands. The closed psychiatric ward is situated in the psychiatric department and is referred to as the intensive care. The ward consists of two separate units with each six rooms. Each patient has a separate bedroom and adjoining bathroom. Both units have their own living room, consulting room, kitchen and a room where smoking is allowed. Both units have access to a central garden. The nursing station is situated at the centre of the ward and serves both units. Both units have three standard patient rooms, one room designed for physically disabled patients, one room with the possibility to lock the door from the outside and one room that can be stripped to be a safe room (also with the possibility to lock the door from the outside). Four seclusion rooms are situated outside the ward, of which a maximum of two can be used at the same time. Two of the seclusion rooms are facilitated with a toilet. All four seclusion rooms have radio and an intercom installation.
Patients are aged 18 – 65 years and are mostly admitted to the hospital on an involuntary basis. Patients are admitted to the ward when there is an acute danger for themselves or their surroundings, due to their psychiatric condition. Most of the patients are diagnosed with schizophrenia or a bipolar disorder.
The nurses at the ward are all qualified and registered in the Dutch registration of healthcare professionals and student nurses. All registered nurses are trained every six months in techniques of verbal de-escalation and safe physical restraint.
Measures
The baseline characteristics of both nurses and patients will be listed. Data will be gathered at each turn of the shift. This means that data are collected three times every 24 hours. The nurses are informed about the fact that the study is conducted at the ward, but they are not informed on the exact hypotheses of the study.
For the group of nurses information is gathered about baseline characteristics. Information is gathered about nurses’ experience, educational level and level of employment. Also personal information like age and sex is used. Information about the stature of the nurse is gathered from length and weight. Also, the stature of the nurses is rated. This is considered to be a qualitative variable, rated by two assessors independently. All these data are chosen because they might influence aggressive behaviour by the patients and the decision for seclusion. For example, an older and experienced male nurse of two meters tall might intimidate the patient more than a young female student nurse. Information about patients who are admitted at the ward will be gathered from the electronic patient record. The patient baseline characteristics are informative for the generalization of our study. We gather information about the sex, age, ethnicity, legal status, diagnosis and so on. Information about the patients’ history on aggression and seclusion is gathered as well.
Unit characteristics are measured from the schedule programme and from the electronic patient record.
We gather information about the unit for each shift. We record which nurses and patients are present at the ward. In this way, we can measure the influence of combined nursing staff factors in order to examine the team influence on seclusion.
For each patient on the ward, the Brøset Violence Checklist (BVC) (11) is assessed twice a day. The BVC is a validated risk assessment tool containing two components. The first component is an objective list of symptoms, which can predict aggression, for example agitation, clamour etc. The second part is a subjective assessment on the risk of aggression, from 1 to 5. The subjective assessment is expressed in a number from 1 (risk of aggression is subjectively assessed as absent) to 5 (risk of aggression is subjectively assessed as very large). The BVC is part of the regular care in our hospital.
We gather information about aggressive incidents from the safety measurement system and from our electronic patient record by examining the daily nursing reports. No structured method of assessing aggressive incidents is used on the ward.
The primary endpoint in our study is the incidence of seclusion. As a secondary endpoint, the duration of the seclusion is measured. The endpoints are measured using the Argus registration system (12). The duration of seclusion gives additional information about the role of seclusion at the ward. When patients are taken out of seclusion, there is a risk that they will get secluded again. Taking patients out of seclusion fast may lead to a higher incidence of seclusions (13). By taking into account the duration of seclusion we tend to give a more accurate picture of the situation on the ward.
The Argus system is a registration system gathering information on involuntary admissions and coerced treatment, of which a psychiatric hospital is obligated to use. From which data must be presented regularly to the Dutch Health Care Inspectorate (IGZ). This system registers every time a patient is secluded, together with the duration of the intervention. These data give a reliable representation of the amount and duration of seclusions on the ward. Information about the reason of seclusion is gathered from the daily nursing report.
Analysis
Our analysis starts with describing the baseline characteristics of the population of nurses and patients.
Nominal and ordinal variables are described by proportions and frequencies. Continuous variables are described by mean and standard deviations or median and range in case of a Non- Gaussian distribution.
The goal of the statistical analysis is to create a valid prediction model to predict seclusion based on the measures as stated in the previous section. The data that we want to use in the prediction model are both (individual) nursing characteristics and unit characteristics. These are two different clusters of data. Our analysis will take into account the correlation within the clusters. For this reason, multilevel regression analysis is used. The dependent variable is involuntary seclusion, according to the definition given in the previous sections. The model is being built by the enter method. For this, a P- value of 0,1 is used. To validate the model, we intend use a bootstrapping procedure.
Because of the nature of the study, missing data cannot be ruled out. For the analysis we accept some missing data, but we watch the standard error closely. If necessary, we use the expected value to impute in our data. All analyses will be performed using SPSS software.
Conclusion
Seclusion is a unavoidable, but controversial intervention with negative consequences for patients. Our study will contribute to gain more insight in nurses’ factors that influence the seclusion rate is essential to develop interventions and create a safe environment for these vulnerable patients.
References
1. Janssen WA, Noorthoorn EO, Vries WJ de, Hutschemaekers GJM, Nijman HLI, Smit A. Separaties in psychiatrische ziekenhuizen 2002-2008: Nederland internationaal vergeleken. Maandblad Geestelijke Volksgezondheid. 2009;64(6):
457-69.
2. Bak J, Aggernæs H. Coercion within Danish psychiatry compared with 10 other European countries. Nord J Psychiatry.
2012;66(5): 297-302.
3. Happel B, Dares G, Russel A, Cokell S, Platania-Phung C, Gaskin CJ. The relationships between attitudes toward seclusion and levels of burnout, staff satisfaction, and therapeutic optimism in a district health care service. Issues Ment Health Nurs.
2012;33(5): 329-336.
4. Vollema MG, Hollants SJ, Severs CJ, Hondius AJK. De determinanten van separaties in een psychiatrische instelling: een naturalistisch en exploratief onderzoek. Tijdschr Psychiatr. 2012;54(3): 211-221.
5. Frueh BC, Knapp RG, Cusak KJ, Grubaugh AL, Sauvageot JA, Cousins VC, Yim E, Robins CS, Monnier J, Hiers TG.
Patients’ reports of traumatic or harmful experiences within the psychiatric setting. Psychatr Serv. 2005;56(9): 1123-1133.
6. GGZ Nederland. De krachten gebundeld: ambities van de GGZ. 2004.
7. IGZ. Terugdringen separeren stagneert, normen vereist rondom insluiting psychiatrische patiënten. Uitkomsten inspectieonderzoek naar de preventie van separeren 2008-2011. Published in December 2011 at http://www.rijksoverheid.
nl/documenten-en- publicaties/rapporten/2011/12/08/terugdringen-separeren-stagneert-normen-vereist- rondom-insluiting-psychiatrische-patienten.html. Accessed on September 7th, 2012.
8. Larue C, Dumais A, Ahern E, Berheim E, Mailhot MP. Factors influencing decisions on seclusion and restraint. J Psychiatr Ment Health Nurs. 2009;16(5): 440-446.
9. Nijman HLI, Duangto C, Ravelli DP, Merckelbach HLGJ, Vorel SK. Personeelskenmerken in relatie tot separatie en afzondering. Tijdschr Psychiatr. 1994;36(2).
10. Janssen WA, Noorthoorn EO, Linge R van, Lendemeijer B. The influence of staffing levels on the use of seclusion. Int J Law Psychiatry. 2007;30(2): 118-126.
11. Clarke DE, Brown AM, Griffith P. The Brøset Violence Checklist: clinical utility in a secure psychiatric intensive care setting. J Psychiatr Ment Health Nurs. 2010;17(7): 614-620.
12. Janssen WA. Argus: assessment and use of data in evaluating coercive measures in Dutch psychiatry. 2012. PhD thesis, Vrije Universiteit. Amsterdam.
13. Noorthoorn E, Janssen W, Hoogendoorn A, Bousardt A, Voskes Y, Smit A, Nijman H, Mulder N, Widdershoven G. . http://
www.veiligezorgiederszorg.nl/speerpunt-dwang-en-drang/vier- jaar-argus.pdf. Accessed on November 28th 2012.
Correspondence
Paul Doedens, RN.
Academic Medical Centre
Department of Psychiatry (room PB01-412) Meibergdreef 5
1105AZ Amsterdam Zuidoost The Netherlands
p.doedens@amc.uva.nl.