0
Get Alert
Please Wait... Processing your request... Please Wait.
You must sign in to sign-up for alerts.

Please confirm that your email address is correct, so you can successfully receive this alert.

Articles   |    
Cluster-Randomized Controlled Trial of Reducing Seclusion and Restraint in Secured Care of Men With Schizophrenia
Anu Putkonen, M.D., Ph.D.; Satu Kuivalainen, R.N., M.Sc.; Olavi Louheranta, Th.M., Ph.D.; Eila Repo-Tiihonen, M.D., Ph.D.; Olli-Pekka Ryynänen, M.D., Ph.D.; Hannu Kautiainen, B.A.; Jari Tiihonen, M.D., Ph.D.
Psychiatric Services 2013; doi: 10.1176/appi.ps.201200393
View Author and Article Information

Dr. Putkonen, Ms. Kuivalainen, Dr Louheranta, and Dr. Repo-Tiihonen are affiliated with the Department of Forensic Psychiatry, University of Eastern Finland (UEF), Kuopio, where Dr. Tiihonen is affiliated, and with Niuvanniemi Hospital, Kuopio. Dr. Tiihonen is also with the Department of Clinical Neuroscience, Karolinska Institutet, Stockholm. Dr. Ryynänen is with the Department of Public Health and Clinical Nutrition, Primary Health Care, UEF. Mr. Kautiainen is with the Unit of Primary Health Care, Helsinki University Central Hospital, and with the Department of General Practice, University of Helsinki in Finland. Send correspondence to Dr. Putkonen, Niuvanniemen sairaala, Niuvankuja 65, 70240 Kuopio, Finland (e-mail: putkonen@niuva.fi).

Copyright © 2013 by the American Psychiatric Association

Abstract

Objective  This randomized controlled trial studied whether seclusion and restraint could be prevented in the psychiatric care of persons with schizophrenia without an increase of violence.

Methods  Over the course of a year, 13 wards of a secured national psychiatric hospital in Finland received information about seclusion and restraint prevention. Four high-security wards (N=88 beds) for men with psychotic illness were then stratified by coercion rates and randomly assigned to two equal groups. In the intervention wards, staff, patients, and doctors were trained for six months in applying six core strategies to prevent seclusion-restraint; six months of supervised intervention followed. Poisson’s regression analyses compared monthly incidence rate ratios (IRRs) of coercion and violence (per 100 patient-days).

Results  The proportion of patient-days with seclusion, restraint, or room observation declined from 30% to 15% for intervention wards (IRR=.88, 95% confidence interval [CI]=.86–.90, p<.001) versus from 25% to 19% for control wards (IRR=.97, CI=.93–1.01, p=.056). Seclusion-restraint time decreased from 110 to 56 hours per 100 patient-days for intervention wards (IRR=.85, CI=.78–.92, p<.001) but increased from 133 to 150 hours for control wards (IRR=1.09, CI=.94–1.25, p=.24). Incidence of violence decreased from 1.1% to .4% for the intervention wards and from .1% to .0% for control wards. Between-groups differences were significant for seclusion-restraint-observation days (p=.001) and seclusion-restraint time (p=.001) but not for violence (p=.91).

Conclusions  Seclusion and restraint were prevented without an increase of violence in wards for men with schizophrenia and violent behavior. A similar reduction may also be feasible under less extreme circumstances.

Abstract Teaser
Figures in this Article

Your Session has timed out. Please sign back in to continue.
Sign In Your Session has timed out. Please sign back in to continue.
Sign In to Access Full Content
 
Username
Password
Sign in via Athens (What is this?)
Athens is a service for single sign-on which enables access to all of an institution's subscriptions on- or off-site.
Not a subscriber?

Subscribe Now/Learn More

PsychiatryOnline subscription options offer access to the DSM-5 library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing PsychiatryOnline@psych.org or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

Figure 1 Proportion of patient-days with seclusion, restraint, or room observation for intervention and control wards during the stabilized interventiona

aError bars indicate 95% confidence intervals (p=.001 for the difference between the groups).

Figure 2 Time spent in seclusion-restraint in intervention and control wards during the stabilized interventiona

aError bars indicate 95% confidence intervals (p≤.001 between groups).

Figure 3 Number of violent incidents in intervention and control wards during the stabilized interventiona

aError bars indicate 95% confidence intervals (p=.91 between groups).

Figure 4 Time patients spent in seclusion-restraint at Niuvanniemi Hospital, 2006–2009a

aThe right panel shows the incidence rate ratios (IRRs), with 2007 as the reference year. Error bars indicate 95% confidence intervals. In 2008 the full hospital staff was informed of the need for and strategies of seclusion-restraint prevention, and hospital leadership started to work as a steering group. In 2009 the intervention took place in two high-security wards.

+

References

Seclusion and Restraint: Position Statement and Standards of Practice. Falls Church, Va, American Psychiatric Nurses Association, May 2000. Revised May 2007. Available at www.apna.org/i4a/pages/index.cfm?pageid=3728
 
Principles for the Protection of Persons With Mental Illness and the Improvement of Mental Health Care, 1991. Adopted by General Assembly resolution 46/119 of Dec 17, 1991. Geneva, Office of the United Nations High Commissioner for Human Rights. Available at www.ohchr.org/EN/ProfessionalInterest/Pages/PersonsWithMentalIllness.aspx
 
 Mental Health Legislation and Human Rights. Mental Health Policy and Service Guidance Package .  Geneva,  World Health Organization, 2003
 
Declaration of Madrid, Spain. Presented at the 10th World Congress of Psychiatry, Chêne-Bourg, Switzerland, Aug 23–28, 1996
 
Council of Europe, Committee of Ministers: Recommendation no Rec(2004)10 of the Committee of Ministers to Member States Concerning the Protection of Human Rights and Dignity of Persons With Mental Disorder and Its Explanatory Memorandum: Adopted by the Committee of Ministers on Sept 22, 2004, at the 896th meeting of the Ministers’ Deputies. Available at www.coe.int/t/dg3/healthbioethic/texts_and_documents/Rec(2004)10_e.pdf
 
Gaskin  CJ;  Elsom  SJ;  Happell  B:  Interventions for reducing the use of seclusion in psychiatric facilities: review of the literature.  British Journal of Psychiatry 191:298–303, 2007
[CrossRef] | [PubMed]
 
Fisher  WA:  Elements of successful restraint and seclusion reduction programs and their application in a large, urban, state psychiatric hospital.  Journal of Psychiatric Practice 9:7–15, 2003
[CrossRef] | [PubMed]
 
Ashcraft  L;  Anthony  W:  Eliminating seclusion and restraint in recovery-oriented crisis services.  Psychiatric Services 59:1198–1202, 2008
[CrossRef] | [PubMed]
 
American Psychiatric Association, American Psychiatric Nurses Association, National Association of Psychiatric Health Systems: Learning From Each Other. Success Stories and Ideas for Reducing Restraint/Seclusion in Behavioral Health, 2003. Available at www.naphs.org
 
Training Curriculum for Creation of Violence-Free, Coercion-Free Treatment Settings and the Reduction of Seclusion and Restraint, 7th ed. Alexandria, Va, National Association of State Mental Health Program Directors, Office of Technical Assistance, 2009
 
LeBel  J;  Stromberg  N;  Duckworth  K  et al:  Child and adolescent inpatient restraint reduction: a state initiative to promote strength-based care.  Journal of the American Academy of Child and Adolescent Psychiatry 43:37–45, 2004
[CrossRef] | [PubMed]
 
Smith  GM;  Davis  RH;  Bixler  EO  et al:  Pennsylvania State Hospital system’s seclusion and restraint reduction program.  Psychiatric Services 56:1115–1122, 2005
[CrossRef] | [PubMed]
 
Barton  SA;  Johnson  MR;  Price  LV:  Achieving restraint-free on an inpatient behavioral health unit.  Journal of Psychosocial Nursing and Mental Health Services 47:34–40, 2009
[CrossRef] | [PubMed]
 
Lewis  M;  Taylor  K;  Parks  J:  Crisis prevention management: a program to reduce the use of seclusion and restraint in an inpatient mental health setting.  Issues in Mental Health Nursing 30:159–164, 2009
[CrossRef] | [PubMed]
 
Sullivan  AM;  Bezmen  J;  Barron  CT  et al:  Reducing restraints: alternatives to restraints on an inpatient psychiatric service—utilizing safe and effective methods to evaluate and treat the violent patient.  Psychiatric Quarterly 76:51–65, 2005
[CrossRef] | [PubMed]
 
Liberman  RP:  Elimination of seclusion and restraint: a reasonable goal? [letter].  Psychiatric Services 4:576, 2006
[CrossRef]
 
Sailas  EA;  Wahlbeck  K:  Restraint and seclusion in psychiatric inpatient wards.  Current Opinion in Psychiatry 18:555–559, 2005
[CrossRef] | [PubMed]
 
Paavola  P;  Tiihonen  J:  Seasonal variation of seclusion incidents from violent and suicidal acts in forensic psychiatric patients.  International Journal of Law and Psychiatry 33:27–34, 2010
[CrossRef] | [PubMed]
 
Campbell  MK;  Elbourne  DR;  Altman  DG  et al:  CONSORT statement: extension to cluster randomised trials.  BMJ 328:702–708, 2004
[CrossRef] | [PubMed]
 
National Executive Training Institute:  Training Curriculum for Reduction of Seclusion and Restraint. Draft Curriculum Manual .  Alexandria, Va,  National Association of State Mental Health Program Directors, National Technical Assistance Center for State Mental Health Planning, 2003
 
Huckshorn  KA:  Reducing seclusion restraint in mental health use settings: core strategies for prevention.  Journal of Psychosocial Nursing 42:22–33, 2004
 
Visalli  H;  McNasser  G;  Johnstone  L  et al:  Reducing high-risk interventions for managing aggression in psychiatric settings.  Journal of Nursing Care Quality 11:54–61, 1997
[CrossRef] | [PubMed]
 
Jonikas  JA;  Cook  JA;  Rosen  C  et al:  A program to reduce use of physical restraint in psychiatric inpatient facilities.  Psychiatric Services 55:818–820, 2004
[CrossRef] | [PubMed]
 
Vaurio  O;  Lankila  J;  Holopainen  S  et al (eds):  Behind Locked Doors: Patient Experiences of Coercion  [in Finnish].  Kuopio, Finland,  Niuvanniemi Hospital, 2009
 
Lebel  J;  Goldstein  R:  The economic cost of using restraint and the value added by restraint reduction or elimination.  Psychiatric Services 56:1109–1114, 2005
[CrossRef] | [PubMed]
 
Abderhalden  C;  Needham  I;  Dassen  T  et al:  Structured risk assessment and violence in acute psychiatric wards: randomised controlled trial.  British Journal of Psychiatry 193:44–50, 2008
[CrossRef] | [PubMed]
 
van de Sande  R;  Nijman  HL;  Noorthoorn  EO  et al:  Aggression and seclusion on acute psychiatric wards: effect of short-term risk assessment.  British Journal of Psychiatry 199:473–478, 2011
[CrossRef] | [PubMed]
 
Keski-Valkama  A:  The Use of Seclusion and Mechanical Restraint in Psychiatry: A Persistent Challenge Over Time .  Tampere, Finland,  Acta Electronica Universitatis, 2010
 
References Container
+
+

CME Activity

There is currently no quiz available for this resource. Please click here to go to the CME page to find another.
Submit a Comments
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of APA editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe



Related Content
Articles
Books
The American Psychiatric Publishing Textbook of Psychopharmacology, 4th Edition > Chapter 62.  >
Manual of Clinical Psychopharmacology, 7th Edition > Chapter 1.  >
The American Psychiatric Publishing Textbook of Geriatric Psychiatry, 4th Edition > Chapter 2.  >
DSM-5™ Clinical Cases > Chapter 3.  >
The American Psychiatric Publishing Textbook of Psychopharmacology, 4th Edition > Chapter 62.  >
Topic Collections
Psychiatric News
APA Guidelines
PubMed Articles