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Research article
Harry G Kennedy
University of Dublin Trinity College
Corresponding Author
ORCiD: https://orcid.org/0000-0003-3174-3272
License:
This work is licensed under a CC BY 4.0 License. Read Full License
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 and inter-rater reliability. 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
Forensic, Psychiatry, Forensic,Violence, Seclusion, Restraint,Observational Study, Coercive
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CURRENT STATUS: Published
View the published article at BMC Psychiatry.
No community comments so far
Editorial decision: Accept
On 09 Oct, 2020
Editor assigned
On 07 Oct, 2020
Submission checks complete
On 06 Oct, 2020
Editor invited
On 06 Oct, 2020
No comments provided
Editorial decision: Minor revision
On 30 Sep, 2020
Review #1 received
Received 22 Aug, 2020
Reviewer #1 agreed
On 20 Aug, 2020
Reviewers invited
Invitations sent on 17 Aug, 2020
Editor assigned
On 11 Aug, 2020
Submission checks complete
On 10 Aug, 2020
Editor invited
On 10 Aug, 2020
Version 1
Posted 08 Apr, 2020
No comments provided
Editorial decision: Major revision
On 01 Jul, 2020
Review #2 received
Received 02 May, 2020
Review #1 received
Received 02 May, 2020
Reviewer #2 agreed
On 23 Apr, 2020
Reviewer #1 agreed
On 15 Apr, 2020
Reviewers invited
Invitations sent on 07 Apr, 2020
Editor assigned
On 02 Apr, 2020
Submission checks complete
On 01 Apr, 2020
Editor invited
On 01 Apr, 2020
First submitted
On 30 Mar, 2020
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
Subject Areas
Psychiatry
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A new preprint design is coming!
We have improved readability, clarity, accessibility, and opportunities for engagement.
See the published version of this preprint at BMC Psychiatry.
This is a preprint, a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
Learn more about In Review
Research article
Harry G Kennedy
University of Dublin Trinity College
Corresponding Author
ORCiD: https://orcid.org/0000-0003-3174-3272
Badges
Prescreen
This manuscript passed our Prescreen assessment
Complete author information
Appropriate declaration statements
Potential risks to human health
Prescreen
Peer Review Timeline
CURRENT STATUS: Published
View the published article at BMC Psychiatry.
No community comments so far
Editorial decision: Accept
On 09 Oct, 2020
Editor assigned
On 07 Oct, 2020
Submission checks complete
On 06 Oct, 2020
Editor invited
On 06 Oct, 2020
No comments provided
Editorial decision: Minor revision
On 30 Sep, 2020
Review #1 received
Received 22 Aug, 2020
Reviewer #1 agreed
On 20 Aug, 2020
Reviewers invited
Invitations sent on 17 Aug, 2020
Editor assigned
On 11 Aug, 2020
Submission checks complete
On 10 Aug, 2020
Editor invited
On 10 Aug, 2020
Version 1
Posted 08 Apr, 2020
No comments provided
Editorial decision: Major revision
On 01 Jul, 2020
Review #2 received
Received 02 May, 2020
Review #1 received
Received 02 May, 2020
Reviewer #2 agreed
On 23 Apr, 2020
Reviewer #1 agreed
On 15 Apr, 2020
Reviewers invited
Invitations sent on 07 Apr, 2020
Editor assigned
On 02 Apr, 2020
Submission checks complete
On 01 Apr, 2020
Editor invited
On 01 Apr, 2020
First submitted
On 30 Mar, 2020
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
Subject Areas
Psychiatry
License:
This work is licensed under a CC BY 4.0 License. Read Full License
View the published article at BMC Psychiatry.
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 and inter-rater reliability. 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.
Figure 1
This is a list of supplementary files associated with this preprint. Click to download.
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