Menstrual Experiences of Totally Blind Menstruators in Kathmandu

Many communities still consider menstruation as a taboo, and thus various restrictions are imposed on menstruators during their menstruation. Despite their challenges, the totally blind menstruators, too, are not spared from the restrictions. This paper presents the findings of a study on menstrual experiences of five totally blind menstruators in Kathmandu, Nepal. Managing their menstruation independently amidst the social and cultural restrictions is far more difficult for blind menstruators because of their needs in terms of support from the family members and physical infrastructures like bathrooms and toilets. The restrictive practice of keeping them in isolation away from their families, whom they rely upon for their day-to-day activities, for up to 22 days during their menarche (first period) not only snatches away their comforts and convenience but also makes them insecure and causes emotional trauma. Ensuring safe and dignified menstruation for blind menstruators needs wider awareness on the realities of menstruation in society, understanding and supportive role of the family, particularly the non-menstruating members, and the appropriate physical infrastructures.

Establishing safety huddles on a general adult acute psychiatric ward: staff's views and relation with restrictive practice

AimsTo establish Safety Huddles (SH) on an acute general adult psychiatric ward, exploring links to restrictive practice. Additionally, to obtain multidisciplinary staff feedback on SH's impact on their workload/wellbeing and on patient care, and to identify barriers in implementation.Background: A SH is a multidisciplinary daily briefing focused on patients most at risk, held at a fixed time and place, lasting max 5-10 minutes. Effective SH involve agreed actions, are informed by multidisciplinary staff feedback of data and provide the opportunity to appreciate and celebrate success in reducing harm. SH are a valuable team building activity, promoting situational awareness and helping with prioritising daily tasks.MethodSH were introduced on September 2020. Templates were developed to prompt staff how to facilitate. Staff were encouraged to identify key goals and reflect on issues in the last and next 24 hours. Each participant was allocated a role, e.g. record keeping or dissemination of information. In December 2020, records of incidence of restrictive practice (numbers of restraints, seclusions and rapid tranquilisations) were obtained for the periods June-August 2020 and September-November 2020. Additionally, staff feedback was obtained through a short anonymous Survey Monkey questionnaire. It explored whether SH had an effect on patient care and staff's workload/wellbeing, and possible barriers to implementation.ResultComparing the two 3-month periods before and after SH implementation, restraint episodes were reduced from 47 to 21, seclusion episodes from 19 to 2, and rapid tranquilisation episodes from 10 to 3. Nine staff members responded to the feedback questionnaire. All believed SH had a positive impact on patient care, or had the potential to do so. Staff reported SH gave them insight into incidents, made them feel safer and prepared for the day, played a part in reducing restrictive practice, and empowered staff from all professional backgrounds by giving them a voice. Low or late participation, cancellation of SH because of clinical activity, and vague questions in the meeting template were identified as barriers in implementation.ConclusionAcute psychiatric wards regularly face challenges of high clinical activity, low staffing levels, bed pressures, and high-risk patient cohorts. SH contributed to reducing restrictive practice and creating a safer and more positive work environment. It is important to ensure SH are taking place daily, using an appropriate template to guide staff who may be new to facilitating. Accordingly, the impact on restrictive practice, patient care and staff wellbeing can be sustained long-term.

Re-audit of use of seclusion in a tier 4 adolescent psychiatric intensive care unit

AimsTo re-audit seclusion practices within a Tier 4 Adolescent PICU provision in London, originally audited in 2018. To ensure restrictive practices are only used in exceptional circumstances for short term risk management. To evaluate whether practice has improved following introduction of incidence reduction strategies and identify any further areas of development.BackgroundThis Tier 4 Adolescent PICU provides treatment of up to 16 high risk and unwell adolescents with severe and enduring mental health illnesses. Seclusion should be a short term risk management strategy with subsequent review of the care plan and treatment. It should be used for the shortest time possible. Following the audit in 2018, three strategies were implemented to reduce restrictive practice: (1) daily nursing safety huddles, (2) weekly Incidence Reduction meetings, and (3) ongoing QI project on restrictive practice.MethodData were collected from all patients requiring seclusion between January and December 2019 (n = 18), which included 46 incidents. Data were collected from RiO computer records, extracting details of patient demographics, reasons and context of seclusion, risk reduction steps prior, length of seclusion, monitoring, and modifications to care plans.ResultAverage length of stay in seclusion was 20h, reduced from 30h previously. Over half of patients requiring seclusion had symptoms of psychosis, consistent with the original audit. Majority of incidents involved assault to staff (80.4%) as indication for seclusion, compared to 50% previously. In 58.7% of cases, verbal de-escalation was followed by further risk reduction with oral medication. Overall, rapid tranquillisation was required in 45.7% of incidents. Restraint was used in 84.8% of incidents, always in combination with at least one other management strategy.Just under half of seclusions were monitored and documented in line with Trust guidelines, however, there was significant improvement in documentation of consultant reviews within 24h from under 70% to over 90%. Care plan modification rates improved from 63% to over 95%.ConclusionMajority of seclusion incidents were due to violent acts by young people presenting with psychotic features/disorder. This reflects the complex nature of psychosis and the substantial need for research to reduce restrictive practice in such cases.Ongoing review of data relating to seclusion will continue to inform and improve practice. This re-audit demonstrates improvement in various areas after implementation of strategies to reduce restrictive practice – importantly, average time in seclusion, documentation of 24 hour consultant reviews and focus on non-pharmacological risk reduction approaches in care plan modifications.

The evaluation of a highly specialist inpatient psychologist working with patients with high risk presentations in an acute mental health inpatient setting

Objective: To evaluate the function and impact of a highly specialist psychologist working with high risk patients in an acute mental health inpatient setting. The impact was examined on outcomes such as risk related incidents, re-admission, average length of stay, and use of restrictive practice.<br/> Method: A mixed methods service evaluation of a pilot project was undertaken to examine the impact of the specialist psychologist role on these outcomes over a 17-month period. Demographic and clinical data was collected for 18 patients who were seen by the psychologist. Routinely collected clinical data examining risk incidents, re-admission rates, average length of stay, and use of restrictive practice, were also used to evaluate outcome across the evaluation period (at baseline and six-month follow-up).<br/> Results: The specialist psychologist provided input to patients' care and undertook a variety of direct and indirect work and training. Examination of descriptive routine clinical data indicated a slight reduction in risk related incidents, readmissions, and average length of stay after the introduction of the psychologist role, however these were not statistically significant.<br/> Conclusion: These initial findings suggest the potential for outcome improvement, but further, more robust research is required to see if such a role can have a significant impact on outcomes.

Reducing restrictive practice: a pertinent issue for children's services

The reduction of restrictive practice has gained momentum in mental health services and it is now becoming evident in mainstream adult services. There remains confusion as to the definition of ‘restrictive practices’ across all sectors of health care, including the difference between ‘restrictive practices’ (such as attitudes of control, limit setting and unnecessary ward rules) and ‘restrictive interventions’ (including physical, chemical or mechanical restraint). This article highlights the relevance of restrictive practice to children's nursing and argues that the principles apply across all health provision. Acts of restrictive practice may result in challenging behaviour, or even restrictive interventions, strategies to minimise both restrictive practice and subsequent acts of challenging behaviour are explored. Behavioural support plans adopting a bio-psycho-pharmaco-social approach have been shown to be effective in both mental health and adult nursing and are recommended for use in children's nursing.

Risk mitigation and the legal and ethical considerations for COVID-19 in a psychiatric inpatient setting

This series of brief reports highlights the experience of a London psychiatric intensive care unit (PICU) that cared for patients with COVID-19 relatively early in the pandemic. The objective is to contribute to learning and consider the challenges for psychiatric intensive care services. This article will discuss COVID-19-related risk prevention and mitigation strategies in a psychiatric inpatient setting, followed by an overview of the legal and ethical challenges, relating to risk prevention, mitigation and restrictive practice, in psychiatric inpatient care during the time of the pandemic.

Benchmarking to reduce restrictive practices in forensic mental health services: a Delphi study

Objectives: Forensic mental health services (FMHS) have higher rates, duration and frequency of restrictive practices (seclusion, physical restraint and mechanical restraint). Data generated by services can be used to set targets (benchmarks) with like services to reduce or eliminate restrictive practices. The aim of this study was to develop restrictive practice benchmarks for Australian and New Zealand FMHS. Method: A participatory action research methodology was used by conducting a Delphi study. FMHS experts provided de-identified service-specific restrictive practice data, which was used to stimulate reflection towards the development of restrictive practice benchmarks. Results: Consensus decision-making was reached on benchmarks for the rate, duration and frequency of seclusion and physical restraint. Mechanical restraint was found to be a rare event, requiring event specific review in each service. Conclusions: Benchmarking with FMHS may assist in working to reduce restrictive practices and encourage the scrutiny of service practice. Establishment of a FMHS network might assist to embed the proposed benchmarks.

How ward rules and limit setting contribute towards restrictive practices and presentations of challenging behaviour in patients on mental health wards

Background/Aims Admission to mental health facilities is often confusing and distressing for patients. Ward rules can help to set out expectations and boundaries but can become restrictive practice when they unnecessarily limit patients. The aim of this study is to understand how ward rules and limit setting can impact on restrictive practice and subsequent challenging behaviour in patients. Methods Three electronic databases were searched (CINAHL, MEDLINE, PsychINFO) using a systematic approach. Seven articles were identified using inclusion/exclusion criteria and findings were synthesised using thematic analysis. Results Six themes were generated finding that ward rules and limit setting could contribute towards challenging behaviour. Passive acceptance could also occur with negative patient outcomes. Conclusions Negative outcomes occurred when patients did not understand or agree with the rule rationale. It also occurred when patients felt a nurse was being emotionally distant or when rule enforcement was one of the only forms of contact.

Sensory room in a psychiatric intensive care unit

Background: The use of sensory-based treatment developed in paediatric and neurodevelopment care is a relatively new practice in psychiatric intensive care and acute mental health settings. This report briefly reviews the literature on the use of sensory rooms in psychiatric intensive care units and acute mental health settings, and outlines the development of a sensory room in a female psychiatric intensive care unit.<br/> Method: We provide an account of the process of establishing a sensory room in a psychiatric intensive care unit setting, including considerations, protocol, training and feedback. The literature on sensory room use in psychiatric intensive care and acute mental health settings was reviewed using the PubMed database and Google Scholar for 'grey' literature.<br/> Results: Widespread positive patient and staff perspectives on sensory room use in psychiatric settings were identified in the literature. Some studies have identified links between sensory-based care and reduced rates of restrictive practice. Feedback from patients using the sensory room established in the report revealed themes of patients enjoying and valuing the practice, and highlighted the need for patient-centred choice in its provision.<br/> Conclusions: This report outlines the development of a sensory room in a female psychiatric intensive care unit and briefly reviews the literature on such, considering its efficacy in both patient experience and possible developments in reducing more restrictive practices in care in this clinical setting. It provides a basis for further evaluation and research on sensory room interventions and their effectiveness in improving clinical outcomes.

Introduction of the Brøset Violence Checklist on a PICU

Background and aims: This survey pragmatically appraised the utility of the Brøset Violence Checklist (BVC) and its potential usefulness in guiding proactive management and interventions to help reduce episodes of violence and/or aggression within a psychiatric intensive care unit (PICU). Emphasis was placed on evaluating whether this instrument was completed prior to an episode of violence and/or aggression, and (through development of an appropriate action plan) the relationship it had on management plans.<br/> Method: Use of the BVC was introduced on a PICU. Incidents of disturbed patient behaviour were collated over a 13 week period using the DATIX incident reporting system. BVC records completed over the 24-hour period prior to any incident were examined. Usage of risk management plans developed after BVC completion was identified. Plans were coded as 'Use of medication', 'Environmental interventions' or 'Restrictive practice'. <br/> Results: 86 incidences were reported. Results suggested satisfactory completion of BVC score sheets for all patients. Management plans were noted as being present and robust for patients whose BVC scores were higher (≥3), as recommended by the tool. It was noted that implementation of restrictive interventions was less than use of either medication or environmental contingencies within proposed risk management plans. However, following an episode, management plans were not reviewed.<br/> Conclusion: An empirically-validated measure to predict potential risk of violence within a PICU was introduced and appropriate management strategy plans developed. Incorporating use of a structured short term risk assessment tool was therefore deemed to be a useful addition to standard procedures.