2 Background
2.3 PIRs – the body of knowledge
To find prevailing literature about PIRs, I started to search broadly in different databases to get an overview over the given field. It soon came up that PIRs (mostly labelled debriefing) mostly were described with respect to accidents and catastrophes and included helping personnel – and to some degree – the victims. Therefore, I turned to Medline, Cinahl and PsychInfo to do more systematic searches of scientific literature. As search terms, I used different variations of debriefing, restraint (mechanical and/or physical) and mental or psychiatric health.
Debriefings after traumatic incidents have been used for a number of years to minimize negative effects of traumatic incidents, initially for emergency service workers and later for wider ranges of traumatic events (Tuckey, 2007). The most frequently used debriefing model, Critical Incident Stress Debriefing (Mitchell, 1983), has been criticized as the involved persons are encouraged to express their emotions after a traumatic incident (Goulet & Larue, 2016). Further, in a Cochrane meta-analysis, Rose et al. (2003) found debriefing to have no effect on reducing post-traumatic stress, and in some cases even indicated a potential to increase risk. The Cochrane study has been criticized by Tuckey (2007), and Goulet and Larue (2016) argue for a debriefing model based on the concepts of psychological debriefing and reflective practice in nursing. This model, which includes patients and care providers, emphasises reflection and learning and thus the patients are not encouraged to express their emotions in the encounter. The objective will then be to help the patients manage their feelings and explore the causes for losing control (Goulet & Larue, 2016).
Fisher (2003) seems to be the first to describe debriefing as a two-step procedure after critical incidents in mental healthcare:
1) debriefing with care providers alone, in post-incident analysis aimed at evaluating what could have been done differently and making short-term plans to avoid repeating restraint use; 2) debriefing for patients and
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Helsebiblioteket.no (2017) that state knowledge-based practice to include scientific knowledge, experiences from care providers and care receivers and user participation.
Quality in mental health services occupies a broad spectrum and may vary across different levels in the healthcare system as managers, care providers, patients and next of kin may have different ideas of what quality means. Public reports state that managers in the services shall strive for quality improvement that includes the employees’ competence development and further securing of patients involvement in treatment and care, where being met with dignity and respect are core values (Norwegian Health Directorate, 2019; Norwegian Social and Health Directorate, 2005).
Care includes being supported to maintain basic needs in a framework of human rights, emphasizing dignity and respect (International Council of Nurses, 2012). Therefore, I will draw on this description of care in relation to PIRs’ accomplishments and outcomes.
In the guidelines to The Mental Care Act, the content in the evaluation is intended to shed light on whether the most appropriate measures were chosen, if restraint was implemented at the right time, if other gentle measures could have been carried out and if the patient received adapted information prior to the implementation (Norwegian Health Directorate, 2017). The patient’s assessment of what triggered the situation in which the coercion was conducted and how new episodes may be prevented is also stated as important to bring forward. Moreover, PIRs should focus on sharing and promoting common situational awareness of the time before, during and after the use of coercive measures.
I have not found any overview with respect to the implementation rate of the PIR procedure in Norway. On request, the Norwegian Directorate of Health claims that they do not have a national overview of the degree of implementation of PIRs and currently have no plans for demanding such reporting.
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2.3 PIRs – the body of knowledge
To find prevailing literature about PIRs, I started to search broadly in different databases to get an overview over the given field. It soon came up that PIRs (mostly labelled debriefing) mostly were described with respect to accidents and catastrophes and included helping personnel – and to some degree – the victims. Therefore, I turned to Medline, Cinahl and PsychInfo to do more systematic searches of scientific literature. As search terms, I used different variations of debriefing, restraint (mechanical and/or physical) and mental or psychiatric health.
Debriefings after traumatic incidents have been used for a number of years to minimize negative effects of traumatic incidents, initially for emergency service workers and later for wider ranges of traumatic events (Tuckey, 2007). The most frequently used debriefing model, Critical Incident Stress Debriefing (Mitchell, 1983), has been criticized as the involved persons are encouraged to express their emotions after a traumatic incident (Goulet & Larue, 2016). Further, in a Cochrane meta-analysis, Rose et al. (2003) found debriefing to have no effect on reducing post-traumatic stress, and in some cases even indicated a potential to increase risk. The Cochrane study has been criticized by Tuckey (2007), and Goulet and Larue (2016) argue for a debriefing model based on the concepts of psychological debriefing and reflective practice in nursing. This model, which includes patients and care providers, emphasises reflection and learning and thus the patients are not encouraged to express their emotions in the encounter. The objective will then be to help the patients manage their feelings and explore the causes for losing control (Goulet & Larue, 2016).
Fisher (2003) seems to be the first to describe debriefing as a two-step procedure after critical incidents in mental healthcare:
1) debriefing with care providers alone, in post-incident analysis aimed at evaluating what could have been done differently and making short-term plans to avoid repeating restraint use; 2) debriefing for patients and
10
Helsebiblioteket.no (2017) that state knowledge-based practice to include scientific knowledge, experiences from care providers and care receivers and user participation.
Quality in mental health services occupies a broad spectrum and may vary across different levels in the healthcare system as managers, care providers, patients and next of kin may have different ideas of what quality means. Public reports state that managers in the services shall strive for quality improvement that includes the employees’ competence development and further securing of patients involvement in treatment and care, where being met with dignity and respect are core values (Norwegian Health Directorate, 2019; Norwegian Social and Health Directorate, 2005).
Care includes being supported to maintain basic needs in a framework of human rights, emphasizing dignity and respect (International Council of Nurses, 2012). Therefore, I will draw on this description of care in relation to PIRs’ accomplishments and outcomes.
In the guidelines to The Mental Care Act, the content in the evaluation is intended to shed light on whether the most appropriate measures were chosen, if restraint was implemented at the right time, if other gentle measures could have been carried out and if the patient received adapted information prior to the implementation (Norwegian Health Directorate, 2017). The patient’s assessment of what triggered the situation in which the coercion was conducted and how new episodes may be prevented is also stated as important to bring forward. Moreover, PIRs should focus on sharing and promoting common situational awareness of the time before, during and after the use of coercive measures.
I have not found any overview with respect to the implementation rate of the PIR procedure in Norway. On request, the Norwegian Directorate of Health claims that they do not have a national overview of the degree of implementation of PIRs and currently have no plans for demanding such reporting.
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PIRs gave them an opportunity to map the incidents that lead up to the event, how the incidents were managed, and whether the incidents could have been predicted. All participants expressed that they valued PIRs, but PIR use was sporadic for the care providers and rarer for the patients.
In several studies, results of implementing S/R reduction programs in different American services were explored (Ashcraft & Anthony, 2008;
Azeem et al., 2011; Fisher, 2003; Scanlan, 2010). The results showed marked decrease in the use of restraint and seclusion in the services after implementation these programs.
Altogether, the existing studies regarding knowledge development and prevention on new restraint episodes of PIRs seemed promising. In three studies, conducting PIRs in a supporting and non-threatening atmosphere was emphasised, but this issue was not further elaborated upon (Azeem et al., 2011; Bonner & Wellman, 2010; Petti et al., 2001).
In summary, PIRs seemed to be a promising intervention with respect to S/R reduction in mental health services. The existing knowledge was immediately vague, as there was no knowledge about how the different elements in the programs contributed to S/R reduction (LeBel et al., 2014; Scanlan, 2010). Stakeholders’, that is, patients’ and care providers’, experiences of participation in PIRs were scarcely described, as the previous studies were small projects from different contexts and with few participants.
Consequently, the results revealed a knowledge gap and a need for up-to-date knowledge and further explorations of patients’ and care providers’ experiences and views of PIRs.
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care providers together, consisting of a detailed behaviour analysis of the events preceding restraint use by both parties.
At the starting point of this PhD project, in 2013, there was to my knowledge just a handful of studies where PIRs after restraint were described. The studies were conducted in England (Bonner et al., 2002;
Bonner & Wellman, 2010) and the USA (Ashcraft & Anthony, 2008;
Azeem et al., 2011; Fisher, 2003; Huckshorn, 2004; Petti et al., 2001).
Studies describing patients’ and care providers’ requests for PIRs and further experiences with PIRs dealt with PIRs after both restraint and seclusion events. Originally, we searched only for research exploring PIRs after restraints, given that restraint and seclusion differ in terms of legality and application, as well as their therapeutic and ethical consequences. In examining the literature, we found that only a few publications fulfilled the criterion regarding restraint alone, so we included publications that either included PIRs after restraints or PIRs after restraints and seclusion together (Arksey & O'Malley, 2005; Boland et al., 2014).
The first two studies that revealed PIRs including patients and care providers as appropriate, were an American study using mixed methods (Petti et al., 2001) and a British small pilot qualitative study (Bonner et al., 2002). The studies explored use of semi-structured interviews after seclusion and restraint, respectively, and physical restraints. In both studies, PIRs were considered to be appropriate tools to map what happened before, during and after the restraint events. Petti et al. (2001) concluded that PIRs ‘can be used as learning tools for staff and patients, to track staff and patient progress, and as a way to change the culture of psychiatric settings’ (p.115).
Bonner and Wellman (2010) used a survey design to evaluate whether patients and care providers found PIRs useful to review incidents of restraint in the practice setting. Ninety-seven percent of staff, and 94%
of patient participants agreed this approach was useful. Furthermore,
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PIRs gave them an opportunity to map the incidents that lead up to the event, how the incidents were managed, and whether the incidents could have been predicted. All participants expressed that they valued PIRs, but PIR use was sporadic for the care providers and rarer for the patients.
In several studies, results of implementing S/R reduction programs in different American services were explored (Ashcraft & Anthony, 2008;
Azeem et al., 2011; Fisher, 2003; Scanlan, 2010). The results showed marked decrease in the use of restraint and seclusion in the services after implementation these programs.
Altogether, the existing studies regarding knowledge development and prevention on new restraint episodes of PIRs seemed promising. In three studies, conducting PIRs in a supporting and non-threatening atmosphere was emphasised, but this issue was not further elaborated upon (Azeem et al., 2011; Bonner & Wellman, 2010; Petti et al., 2001).
In summary, PIRs seemed to be a promising intervention with respect to S/R reduction in mental health services. The existing knowledge was immediately vague, as there was no knowledge about how the different elements in the programs contributed to S/R reduction (LeBel et al., 2014; Scanlan, 2010). Stakeholders’, that is, patients’ and care providers’, experiences of participation in PIRs were scarcely described, as the previous studies were small projects from different contexts and with few participants.
Consequently, the results revealed a knowledge gap and a need for up-to-date knowledge and further explorations of patients’ and care providers’ experiences and views of PIRs.
12
care providers together, consisting of a detailed behaviour analysis of the events preceding restraint use by both parties.
At the starting point of this PhD project, in 2013, there was to my knowledge just a handful of studies where PIRs after restraint were described. The studies were conducted in England (Bonner et al., 2002;
Bonner & Wellman, 2010) and the USA (Ashcraft & Anthony, 2008;
Azeem et al., 2011; Fisher, 2003; Huckshorn, 2004; Petti et al., 2001).
Studies describing patients’ and care providers’ requests for PIRs and further experiences with PIRs dealt with PIRs after both restraint and seclusion events. Originally, we searched only for research exploring PIRs after restraints, given that restraint and seclusion differ in terms of legality and application, as well as their therapeutic and ethical consequences. In examining the literature, we found that only a few publications fulfilled the criterion regarding restraint alone, so we included publications that either included PIRs after restraints or PIRs after restraints and seclusion together (Arksey & O'Malley, 2005; Boland et al., 2014).
The first two studies that revealed PIRs including patients and care providers as appropriate, were an American study using mixed methods (Petti et al., 2001) and a British small pilot qualitative study (Bonner et al., 2002). The studies explored use of semi-structured interviews after seclusion and restraint, respectively, and physical restraints. In both studies, PIRs were considered to be appropriate tools to map what happened before, during and after the restraint events. Petti et al. (2001) concluded that PIRs ‘can be used as learning tools for staff and patients, to track staff and patient progress, and as a way to change the culture of psychiatric settings’ (p.115).
Bonner and Wellman (2010) used a survey design to evaluate whether patients and care providers found PIRs useful to review incidents of restraint in the practice setting. Ninety-seven percent of staff, and 94%
of patient participants agreed this approach was useful. Furthermore,
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2.5 Focus and delimitations
In respect to the main aim of this thesis, the focus is PIRs after restraint events, and therefore not the restraint itself. A central aspect throughout will be patients’ dependent position in mental health care services and therefore exposure to dehumanising experiences.
The procedures are already implemented in the participating services.
The focuses of the empirical sub-studies are, accordingly, stakeholders’
experiences and opinions, and consequently not measures of effect or comparative studies. Furthermore, the empirical studies will be experiences from a Norwegian context.
2.6 Use of concepts
Traditionally, people with mental health problems have been labelled as patients. According to Norwegian law, people are patients when they receive medical treatment (Norwegian Ministry of Health & Care Services, 1999, §1.3) In studies presented in Article 1, different terms are used to describe people with mental health challenges, but we chose to make use of the concept ‘patient’ due to the law. In article 2 and 3, we used the concept ‘patients’ even though some of the participants no longer were inpatients when they shared their experiences and views.
The term ‘service user’ would then be more precise for out-patients, but for the sake of readership I chose to use the term patient in this thesis.
When exploring professionals’ experiences and considerations, a multidisciplinary focus was chosen. Psychologists and doctors bear the formal responsibility for the decision to restrain. Milieu therapists bear the responsibility for care before, during, and after the restraint events.
They also conducted PIRs when the patient’s therapist was hindered.
Therefore, the term care provider is used in this project. As most of the research with respect to milieu therapy is about nurses, and most interviewed milieu therapists were nurses, I use the term nurse in the thesis when I mention milieu therapists.
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