A tool to evaluate proportionality and necessity in the use of restrictive practices in forensic mental health settings: the DRILL tool (Dundrum restriction, intrusion and liberty ladders)

Harry G Kennedy, Ronan Mullaney, Paul McKenna, John Thompson, David Timmons, Pauline Gill, Owen P O'Sullivan, Paul Braham, Dearbhla Duffy, Anthony Kearns, Sally Linehan, Damian Mohan, Stephen Monks, Lisa McLoughlin, Paul O'Connell, Conor O'Neill, Brenda Wright, Ken O'Reilly, Mary Davoren, Harry G Kennedy, Ronan Mullaney, Paul McKenna, John Thompson, David Timmons, Pauline Gill, Owen P O'Sullivan, Paul Braham, Dearbhla Duffy, Anthony Kearns, Sally Linehan, Damian Mohan, Stephen Monks, Lisa McLoughlin, Paul O'Connell, Conor O'Neill, Brenda Wright, Ken O'Reilly, Mary Davoren

Abstract

Background: Prevention of violence due to severe mental disorders in psychiatric hospitals may require intrusive, restrictive and coercive therapeutic practices. Research concerning appropriate use of such interventions is limited by lack of a system for description and measurement. We set out to devise and validate a tool for clinicians and secure hospitals to assess necessity and proportionality between imminent violence and restrictive practices including de-escalation, seclusion, restraint, forced medication and others.

Methods: In this retrospective observational cohort study, 28 patients on a 12 bed male admissions unit in a secure psychiatric hospital were assessed daily for six months. Data on adverse incidents were collected from case notes, incident registers and legal registers. Using the functional assessment sequence of antecedents, behaviours and consequences (A, B, C) we devised and applied a multivariate framework of structured professional assessment tools, common adverse incidents and preventive clinical interventions to develop a tool to analyse clinical practice. We validated by testing assumptions regarding the use of restrictive and intrusive practices in the prevention of violence in hospital. We aimed to provide a system for measuring contextual and individual factors contributing to adverse events and to assess whether the measured seriousness of threating and violent behaviours is proportionate to the degree of restrictive interventions used. General Estimating Equations tested preliminary models of contexts, decisions and pathways to interventions.

Results: A system for measuring adverse behaviours and restrictive, intrusive interventions for prevention had good internal consistency. Interventions were proportionate to seriousness of harmful behaviours. A 'Pareto' group of patients (5/28) were responsible for the majority (80%) of adverse events, outcomes and interventions. The seriousness of the precipitating events correlated with the degree of restrictions utilised to safely manage or treat such behaviours.

Conclusion: Observational scales can be used for restrictive, intrusive or coercive practices in psychiatry even though these involve interrelated complex sequences of interactions. The DRILL tool has been validated to assess the necessity and demonstrate proportionality of restrictive practices. This tool will be of benefit to services when reviewing practices internally, for mandatory external reviewing bodies and for future clinical research paradigms.

Keywords: Coercive; Forensic; Forensic psychiatry; Observational Study; Restraint; Seclusion; Violence.

Conflict of interest statement

The authors declare no competing interests. Harry G. Kennedy is an associate editor of BMC Psychiatry but has had no editorial role in the processing of this manuscript.

Figures

Fig. 1
Fig. 1
Milieu and individual context-decision-path.

References

    1. Kennedy HG. Therapeutic uses of security: mapping forensic mental health services by stratifying risk. Adv Psychiatr Treat. 2002;8(6):433–443. doi: 10.1192/apt.8.6.433.
    1. Seppanen A, Tormanen I, Shaw C, Kennedy H. Modern forensic psychiatric hospital design: clinical, legal and structural aspects. Int J Ment Health Syst. 2018;12:58. doi: 10.1186/s13033-018-0238-7.
    1. Sailas E, Fenton M. Seclusion and restraint for people with serious mental illnesses. Cochrane Database Syst Rev. 2000;2000(2):Cd001163.
    1. Muralidharan S, Fenton M. Containment strategies for people with serious mental illness. Cochrane Database Syst Rev. 2006;3:Cd002084.
    1. Howner K, Andiné P, Bertilsson G, Hultcrantz M, Lindström E, Mowafi F, et al. Mapping systematic reviews on forensic psychiatric care: a systematic review identifying knowledge gaps. Front Psychiatry. 2018;9:452. doi: 10.3389/fpsyt.2018.00452.
    1. Broderick C, Azizian A, Kornbluh R, Warburton K. Prevalence of physical violence in a forensic psychiatric hospital system during 2011-2013: patient assaults, staff assaults, and repeatedly violent patients. CNS Spectr. 2015;20(3):319–330. doi: 10.1017/S1092852915000188.
    1. Juran JM. Pareto, lorenz, cournot, bernoulli, juran and others. Joseph M Juran: Critical Evaluations in Business and Management. 2005;1(4):47.
    1. Kennedy HG, Kemp LI, Dyer DE. Fear and anger in delusional (paranoid) disorder: the association with violence. Br J Psychiatry. 1992;160:488–492. doi: 10.1192/bjp.160.4.488.
    1. O'Reilly K, O'Connell P, Corvin A, O'Sullivan D, Coyle C, Mullaney R, et al. Moral cognition and homicide amongst forensic patients with schizophrenia and schizoaffective disorder: a cross-sectional cohort study. Schizophr Res. 2018;193:468–469. doi: 10.1016/j.schres.2017.07.026.
    1. O'Reilly K, O'Connell P, O'Sullivan D, Corvin A, Sheerin J, O'Flynn P, et al. Moral cognition, the missing link between psychotic symptoms and acts of violence: a cross-sectional national forensic cohort study. BMC Psychiatry. 2019;19(1):408. doi: 10.1186/s12888-019-2372-4.
    1. O'Reilly K, Donohoe G, Coyle C, O'Sullivan D, Rowe A, Losty M, et al. Prospective cohort study of the relationship between neuro-cognition, social cognition and violence in forensic patients with schizophrenia and schizoaffective disorder. BMC Psychiatry. 2015;15:155. doi: 10.1186/s12888-015-0548-0.
    1. Care Quality Commission. Mental health act. A focus on restrictive intervention reduction programmes in in-patient mental health services. 2017.
    1. Hawkes N. Mental health Act: care on wards is often unsafe and poor quality, says watchdog. BMJ. 2019;364:l911.
    1. Bowers L, Cullen AE, Achilla E, Baker J, Khondoker M, Koeser L, et al. Health Services and Delivery Research. Seclusion and Psychiatric Intensive Care Evaluation Study (SPICES): combined qualitative and quantitative approaches to the uses and outcomes of coercive practices in mental health services. Southampton (UK): NIHR Journals Library. 2017. 10.3310/hsdr05210.
    1. Council of Europe: Committee for the Prevention of Torture, Means of restraint in psychiatric establishments for adults (revised CPT standards), 21 March 2017, CPT/Inf(2017)6, available at: . Accessed 18 Oct 2020.
    1. Kallert TW, Glöckner M, Onchev G, Raboch J, Karastergiou A, Solomon Z, et al. The EUNOMIA project on coercion in psychiatry: study design and preliminary data. World Psychiatry. 2005;4(3):168–172.
    1. Thomas SDM, Daffern M, Martin T, Ogloff JRP, Thomson LDG, Ferguson M. Factors associated with seclusion in a statewide forensic psychiatric service in Australia over a 2-year period. Int J Ment Health Nurs. 2009;18(1):2–9. doi: 10.1111/j.1447-0349.2008.00567.x.
    1. Wong JG, Clare IC, Gunn MJ, Holland AJ. Capacity to make health care decisions: its importance in clinical practice. Psychol Med. 1999;29(2):437–446. doi: 10.1017/S0033291798008113.
    1. Moynihan G, O'Reilly K, O'Connor J, Kennedy HG. An evaluation of functional mental capacity in forensic mental health practice: the Dundrum capacity ladders validation study. BMC Psychiatry. 2018;18(1):78. doi: 10.1186/s12888-018-1658-2.
    1. Fernandez C, Kennedy HG, Kennedy M. The recovery of factors associated with decision-making capacity in individuals with psychosis. BJPsych Open. 2017;3(3):113–119. doi: 10.1192/bjpo.bp.116.004226.
    1. Rutledge E, Kennedy M, O'Neill H, Kennedy HG. Functional mental capacity is not independent of the severity of psychosis. Int J Law Psychiatry. 2008;31(1):9–18. doi: 10.1016/j.ijlp.2007.11.002.
    1. Kennedy M, Dornan J, Rutledge E, O'Neill H, Kennedy HG. Extra information about treatment is too much for the patient with psychosis. Int J Law Psychiatry. 2009;32(6):369–376. doi: 10.1016/j.ijlp.2009.09.006.
    1. Szmukler G, Appelbaum PS. Treatment pressures, leverage, coercion, and compulsion in mental health care. J Ment Health. 2008;17(3):233–244. doi: 10.1080/09638230802052203.
    1. Katsakou C, Bowers L, Amos T, Morriss R, Rose D, Wykes T, et al. Coercion and treatment satisfaction among involuntary patients. Psychiatr Serv. 2010;61(3):286–292. doi: 10.1176/ps.2010.61.3.286.
    1. O'Donoghue B, Lyne J, Hill M, Larkin C, Feeney L, O'Callaghan E. Physical coercion, perceived pressures and procedural justice in the involuntary admission and future engagement with mental health services. Eur Psychiatry. 2011;26(4):208–214. doi: 10.1016/j.eurpsy.2010.01.014.
    1. Owen GS, David AS, Hayward P, Richardson G, Szmukler G, Hotopf M. Retrospective views of psychiatric in-patients regaining mental capacity. Br J Psychiatry. 2009;195(5):403–407. doi: 10.1192/bjp.bp.109.065151.
    1. Kothari AR, Bickford JJ, Edwards N, Dobbins MJ, Meyer M. Uncovering tacit knowledge: a pilot study to broaden the concept of knowledge in knowledge translation. BMC Health Serv Res. 2011;11:198. doi: 10.1186/1472-6963-11-198.
    1. Von Bertalanffy L. General system theory: foundations, development, applications. New York: Georges Braziller, Inc.; 1993.
    1. Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry. 1980;137(5):535–544. doi: 10.1176/ajp.137.5.535.
    1. AGENCY FOR CLINICAL INNOVATION . Understanding the process to develop a Model of Care An ACI Framework,. Version 1.0, May 2013 ed. Chatsworth New South Wales Australia: NSW Agency for Clinical Innovation; 2013.
    1. Gudjonsson G, Rabe-hesketh S, Wilson C. Violent incidents on a medium secure unit over a 17-year period. J Forensic Psychiatry. 1999;10(2):249–263. doi: 10.1080/09585189908403679.
    1. Välimäki M, Yang M, Vahlberg T, Lantta T, Pekurinen V, Anttila M, et al. Trends in the use of coercive measures in Finnish psychiatric hospitals: a register analysis of the past two decades. BMC Psychiatry. 2019;19(1):230. doi: 10.1186/s12888-019-2200-x.
    1. Abderhalden C, Needham I, Dassen T, Halfens R, Haug HJ, Fischer JE. Structured risk assessment and violence in acute psychiatric wards: randomised controlled trial. Br J Psychiatry. 2008;193(1):44–50. doi: 10.1192/bjp.bp.107.045534.
    1. Hvidhjelm J, Sestoft D, Skovgaard LT, Rasmussen K, Almvik R, Bue BJ. Aggression in psychiatric wards: effect of the use of a structured risk assessment. Issues Ment Health Nurs. 2016;37(12):960–967. doi: 10.1080/01612840.2016.1241842.
    1. Kaunomäki J, Jokela M, Kontio R, Laiho T, Sailas E, Lindberg N. Interventions following a high violence risk assessment score: a naturalistic study on a Finnish psychiatric admission ward. BMC Health Serv Res. 2017;17(1):26. doi: 10.1186/s12913-016-1942-0.
    1. Maguire T, Daffern M, Bowe SJ, McKenna B. Predicting aggressive behaviour in acute forensic mental health units: a re-examination of the dynamic appraisal of situational aggression's predictive validity. Int J Ment Health Nurs. 2017;26(5):472–481. doi: 10.1111/inm.12377.
    1. Maguire T, Daffern M, Bowe SJ, McKenna B. Risk assessment and subsequent nursing interventions in a forensic mental health inpatient setting: associations and impact on aggressive behaviour. J Clin Nurs. 2018;27(5–6):e971–ee83. doi: 10.1111/jocn.14107.
    1. Maguire T, Daffern M, Bowe SJ, McKenna B. Evaluating the impact of an electronic application of the dynamic appraisal of situational aggression with an embedded aggression prevention protocol on aggression and restrictive interventions on a forensic mental health unit. Int J Ment Health Nurs. 2019;28(5):1186–1197. doi: 10.1111/inm.12630.
    1. Stensgaard L, Andersen MK, Nordentoft M, Hjorthøj C. Implementation of the safewards model to reduce the use of coercive measures in adult psychiatric inpatient units: an interrupted time-series analysis. J Psychiatr Res. 2018;105:147–152. doi: 10.1016/j.jpsychires.2018.08.026.
    1. Ogloff JR, Daffern M. The dynamic appraisal of situational aggression: an instrument to assess risk for imminent aggression in psychiatric inpatients. Behav Sci Law. 2006;24(6):799–813. doi: 10.1002/bsl.741.
    1. Almvik R, Woods P, Rasmussen K. The Brøset violence checklist: sensitivity, specificity, and interrater reliability. J Interpersonal Violence. 2000;15(12):1284–1296. doi: 10.1177/088626000015012003.
    1. Ullrich S, Keers R, Coid JW. Delusions, anger, and serious violence: new findings from the MacArthur violence risk assessment study. Schizophr Bull. 2014;40(5):1174–1181. doi: 10.1093/schbul/sbt126.
    1. Chu CM, Daffern M, Ogloff JRP. Predicting aggression in acute inpatient psychiatric setting using BVC, DASA, and HCR-20 clinical scale. J Forensic Psychiatry Psychol. 2013;24(2):269–285. doi: 10.1080/14789949.2013.773456.
    1. Flynn G, O'Neill C, McInerney C, Kennedy HG. The DUNDRUM-1 structured professional judgment for triage to appropriate levels of therapeutic security: retrospective-cohort validation study. BMC Psychiatry. 2011;11:43. doi: 10.1186/1471-244X-11-43.
    1. Kennedy H, O'Neill C, Flynn G, Gill P, Davoren M. DANGEROUSNESS UNDERSTANDING, RECOVERY and URGENCY MANUAL (THE DUNDRUM QUARTET) V1.0.26 (01/08/13) Four Structured Professional Judgement Instruments for Admission Triage, Urgency, Treatment Completion and Recovery Assessments. 2013.
    1. Law Reform Commission: Mental Health Act 2001 (25/2001). Revised Updated to 30 March 2020. Part 3 Independent review of detention. Available at: and . Accessed 18 Oct 2020.
    1. Mental Health Commission . Rules Governing the use of Seclusion and Mechanical Means of Bodily Restraint Dublin, Ireland: Mental Health Commission. 2010.
    1. Müller-Isberner R, Webster CD, Gretenkord L. Measuring Progress in hospital order treatment: relationship between levels of security and C and R scores of the HCR-20. Int J Forensic Ment Health. 2007;6(2):113–121. doi: 10.1080/14999013.2007.10471256.
    1. Pillay SM, Oliver B, Butler L, Kennedy HG. Risk stratification and the care pathway. Ir J Psychol Med. 2008;25(4):123–127. doi: 10.1017/S0790966700011228.
    1. McCullough S, Stanley C, Smith H, Scott M, Karia M, Ndubuisi B, et al. Outcome measures of risk and recovery in Broadmoor high secure forensic hospital: stratification of care pathways and moves to medium secure hospitals. BJPsych Open. 2020;6(4):e74. doi: 10.1192/bjo.2020.61.
    1. Worrall A. The service context for clinical guidelines: supporting guideline implementation by assuring and improving the quality of service in which clinicians work. International Review of Psychiatry. 2011;23(4):336–341. doi: 10.3109/09540261.2011.606542.
    1. Freestone M, Bull D, Brown R, Boast N, Blazey F, Gilluley P. Triage, decision-making and follow-up of patients referred to a UK forensic service: validation of the DUNDRUM toolkit. BMC Psychiatry. 2015;15:239. doi: 10.1186/s12888-015-0620-9.
    1. Lawrence D, Davies TL, Bagshaw R, Hewlett P, Taylor P, Watt A. External validity and anchoring heuristics: application of DUNDRUM-1 to secure service gatekeeping in South Wales. BJPsych Bull. 2018;42(1):10–18. doi: 10.1192/bjb.2017.6.
    1. Jeandarme I, Habets P, Kennedy H. Structured versus unstructured judgment: DUNDRUM-1 compared to court decisions. Int J Law Psychiatry. 2019;64:205–210. doi: 10.1016/j.ijlp.2019.04.006.
    1. Jones RM, Patel K, Simpson AIF. Assessment of need for inpatient treatment for mental disorder among female prisoners: a cross-sectional study of provincially detained women in Ontario. BMC Psychiatry. 2019;19(1):98. doi: 10.1186/s12888-019-2083-x.
    1. Adams J, Thomas SDM, Mackinnon T, Eggleton D. The risks, needs and stages of recovery of a complete forensic patient cohort in an Australian state. BMC Psychiatry. 2018;18(1):35. doi: 10.1186/s12888-017-1584-8.
    1. Williams HK, Senanayke M, Ross CC, Bates R, Davoren M. Security needs among patients referred for high secure care in Broadmoor hospital England. BJPsych Open. 2020;6(4):e55. doi: 10.1192/bjo.2020.35.
    1. Haque Q, Webster CD. Structured professional judgement and sequential redirections. Crim Behav Ment Health. 2013;23(4):241–251. doi: 10.1002/cbm.1886.
    1. Schalast N, Redies M, Collins M, Stacey J, Howells K. EssenCES, a short questionnaire for assessing the social climate of forensic psychiatric wards. Crim Behav Ment Health. 2008;18(1):49–58. doi: 10.1002/cbm.677.
    1. MacInnes D, Beer D, Keeble P, Rees D, Reid L. The development of a tool to measure service user satisfaction with in-patient forensic services: the forensic satisfaction scale. J Ment Health. 2010;19(3):272–281. doi: 10.3109/09638231003728133.
    1. Fagan J, Ijaz A, Papaconstantinou A, Lynch A, O'Neill H, Kennedy HG. The suicide risk assessment and management manual (S-RAMM) validation study II. Ir J Psychol Med. 2009;26(3):107–113. doi: 10.1017/S0790966700000380.
    1. SanSegundo MS, Ferrer-Cascales R, Bellido JH, Bravo MP, Oltra-Cucarella J, Kennedy HG. rediction of violence, Suicide Behaviors and Suicide Ideation in a Sample of Institutionalized Offenders With Schizophrenia and Other Psychosis. Front Psychol. 2018;9:1385. doi: 10.3389/fpsyg.2018.01385.
    1. Evans CH, Margison F, Barkham M. The contribution of reliable and clinically significant change methods to evidence-based mental health. Evidence Based Mental Health. 1998;1:70–72. doi: 10.1136/ebmh.1.3.70.
    1. Coid JW, Ullrich S, Kallis C, Freestone M, Gonzalez R, Bui L, et al. Programme Grants for Applied Research. Improving risk management for violence in mental health services: a multimethods approach. Southampton: NIHR Journals Library; 2016. 10.3320/pgfar04160.
    1. Freestone MC, Ullrich S, Coid JW. External trigger factors for violent offending: findings from the U.K. prisoner cohort study. Crim Justice Behav. 2017;44(11):1389–1412. doi: 10.1177/0093854817713237.
    1. James DV, Fineberg NA, Shah AK, Priest RG. An increase in violence on an acute psychiatric ward. A study of associated factors. Br J Psychiatry. 1990;156:846–852. doi: 10.1192/bjp.156.6.846.
    1. 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. Int J Soc Psychiatry. 2007;53(1):75–84. doi: 10.1177/0020764007075011.
    1. Stewart D, Bowers L. Under the gaze of staff: special observation as surveillance. Perspect Psychiatr Care. 2012;48(1):2–9. doi: 10.1111/j.1744-6163.2010.00299.x.
    1. Kennedy HG, Timmons D, Gill P, McKenna P, Braham P, Mullaney R. DUNDRUM Restriction and Intrusion Liberty Ladders (DRILL) 2011 V 1.0.4 14 November 2011 (handbook ). Dublin Ireland: Trinity's Access to Research Archive (TARA) Trinity College Dublin; 2011. Available from: .
    1. IBM Corp . IBM SPSS statistics for windows, version 25.0. IBM Corp: Armonk NY; 2017.
    1. Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika. 1951;16:297–334. doi: 10.1007/BF02310555.
    1. Alper S, Bayrak F, Us EÖ, Yilmaz O. Do changes in threat salience predict the moral content of sermons? The case of Friday Khutbas in Turkey. Eur J Soc Psychol. 2020;50(3):662–672. doi: 10.1002/ejsp.2632.
    1. Joseph M, Juran JA. De Feo. Juran's Quality Handbook: The Complete Guide to Performance Excellence, Sixth Edition,. 6th ed. New York: McGraw-Hill Education; 2010.
    1. Kennedy HG, O’Neill C, Flynn G, Gill P, Davoren M. Dangerousness understanding, recovery and urgency manual (the DUNDRUM quartet) V1. 0. 26 (01/08/13) four structured professional judgement instruments for admission triage, urgency, treatment completion and recovery assessments. Dublin Ireland: Trinity College Dublin; 2013.
    1. Goren S, Singh NN, Best AM. The aggression-coercion cycle: use of seclusion and restraint in a child psychiatric hospital. J Child Fam Stud. 1993;2(1):61–73. doi: 10.1007/BF01321301.
    1. Ferns T, Chojnacka I. Reporting incidents of violence and aggression towards NHS staff. Nurs Stand. 2005;19(38):51–56. doi: 10.7748/ns.19.38.51.s50.
    1. Chow WS, Priebe S. Understanding psychiatric institutionalization: a conceptual review. BMC Psychiatry. 2013;13(1):169. doi: 10.1186/1471-244X-13-169.
    1. Sharma A, Dunn W, O’Toole C, Kennedy HG. The virtual institution: cross-sectional length of stay in general adult and forensic psychiatry beds. Int J Ment Heal Syst. 2015;9(1):25. doi: 10.1186/s13033-015-0017-7.
    1. Gadon L, Johnstone L, Cooke D. Situational variables and institutional violence: a systematic review of the literature. Clin Psychol Rev. 2006;26(5):515–534. doi: 10.1016/j.cpr.2006.02.002.
    1. Kelly BD. Structural violence and schizophrenia. Soc Sci Med. 2005;61(3):721–730. doi: 10.1016/j.socscimed.2004.12.020.
    1. Kelly BD. The power gap: freedom, power and mental illness. Soc Sci Amp; Med (1982) 2006;63(8):2118–2128. doi: 10.1016/j.socscimed.2006.05.015.
    1. National Ethical Advisory Committee. Ethical Guidelines for Observational Studies: Observational Research, Audits and Related Activities. Ministry of Health, Wellington, NZ; 2012. 2014.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera