Course Project: Part 2 — Literature Review

NURS 6052: Essentials of Evidence-Based PracticeFrank BashumikaWalden UniversityMarch 30, 2019Course Project: Part 2 — Literature Review Problem AnalysisThe use of seclusion and restrictions (SR) in psychiatric care has continued, worldwide, despite the well-documented physical and psychological harm to patient outcomes (Goethals, Dierckx, and Gastmans, 2012; Hamers & Huizing, 2005). Various studies have established that these measures are not effective in preventing or containing patient aggression, and, therefore, their use is not evidence-based (Kaucic, 2017). Acting on the study findings, regulatory authorities and professional bodies such as the American Psychiatric Nurses Association (APNA, 2014), Centers for Medicare and Medicaid Services (CMMS, 2012), American Nurses Association. (2015), and Mental Health America (MHA, n.d.) have recommended alternative patient aggression control skills and eventual elimination of SR use. This paper examines five existing primary studies with a view to understanding the different types of available alternative interventions and any barriers to their implementation. MethodFive recent primary research publications were reviewed. As dictated by the nature of the problem under investigation, the review covered only those studies which had investigated the experiences and attitude of the populations that are most affected by the practice of SR towards the interventions: patients and nurses. The guiding, previously formulated, (PICOT) question was: “In psychiatric patient care (P), what is the most effective method of promoting alternative interventions (I) with a view to ending the use of SR (C, O) in the least time possible (T)?P= psychiatric inpatients I= SRC= alternative interventions O= abolition of SR useT= the least time possible This question guided the critical examination of the various studies to identify their outcomes, in/consistencies, and to determine any need for further research on the topic.The five publications were accessed in the Walden Library through a search of the following databases: CINAHL Plus with Full Text, MEDLINE with Full Text, and PsycINFO. The search from these databases provided trusted information because the databases usually accept only plausible publications. The key search words were: seclusion, restraints, reduction, elimination, barriers, psychiatric, and alternatives. ‘Seclusion’ and ‘restraints’ were the common search words in all searches. Initial search generated about 75 publications which were sieved down to 33 by excluding those whose full text was not available. Upon examination of the abstract of the remaining 35 publications, only ten were found to have close relevance to the question under investigation. They were further trimmed by reading them and selecting those with the highest relevance level.Literature ReviewThe reviewed studies, a mix of qualitative and quantitative studies, reported various alternative interventions including de-escalation methods, sensory modulation, and time-out (Bowers et al, 2012; Godfrey et al, 2014). Other studies promoted formal alternatives: the Safewards model and Six Score Strategies (Bowers et al, 2015; Wieman et al, 2014; and Guzman et al, 2016). All the alternatives, especially the formal ones, which took into consideration patients’ attitude and perceptions, were reported to improve patient satisfaction with care (Bowers et al, 2015; Bowers et al, 2012; Godfrey et al, 2014). The literature consistently reported the patients’ and nurses’ distaste for SR use. Patients distasted the interventions because they violated patients’ human rights – autonomy and access to basic needs. Studies found that patients did not see the need for the use of SR. Nurses on their part were reported to be in a state of ethical dilemma, for whereas they too distasted SR use, they could not help applying them due to ‘lack of alternatives’. The studies, thus identified nurses’ general ignorance of available alternative patient aggression management skills. This was presented as the key barrier to the implementation of alternative interventions although the studies suggested that the barrier could be overcome.ConclusionThe literature reviewed confirmed the availability of alternative clinical strategies and skills that may be applied to either decrease or eliminate SR use. The consistency of findings establishes the reliability and validity of the information presented by the studies. They present strong support for a change in practice although further research may be desirable to determine the feasibility of each of the alternative interventions. Further research may identify the most effective alternative(s) and establish best practice in the actual intervention implementation. ReferencesAmerican Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Retrieved from http://nursingworld.org/DocumentVault/Ethics -1/Code-of-Ethics-for-Nurses.htmlAmerican Psychiatric Nurses Association. (2014). APNA position statement on the use of seclusion and restraint. Retrieved from http://www.apna.org/i4a/pages/index.cfm?pageid=3728Bowers, L., James, K., Quirk, A., Simpson, A., Stewart, D., & Hodsoll, J. (2015). Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomized controlled trial. International Journal of Nursing Studies, 52(9), 1412 -1422. doi:10.1016/j.Bowers, L., Ross, J., Nijman, H., Muir-Cochrane, E., Noorthoorn, E., & Stewart, D. (2012). The scope for replacing seclusion with time out in acute Inpatient psychiatry in England. Journal Of Advanced Nursing, 68(4), 826 – 835 10p. doi:10.1111/j. 1365-2648.2011.05 784.x.Centers for Medicare and Medicaid Services, HHS. (2012). Condition of participation: Patients’ rights (CFR Title 42 Section 482.13). Washington, DC: U.S. Government Printing Office.Davies, K.S. (2011). Formulating the evidence-based practice question: A review of the frameworks for LIS professionals.  Evidence Based Library and Information Practice 6(2):75-80. Retrieved March 10, 2019, from https://www.researchgate.net/publication/229115669_Formulating_the_Evidence_Based_Practice_question_A_review_of_the_frameworks_for_LIS_professionalsGodfrey, J. L., McGill, A. C., Jones, N. T., Oxley, S. L., & Carr, R. M. (2014). Anatomy of a transformation: A systematic effort to reduce mechanical restraints at a state psychiatric hospital. Psychiatric Services (Washington, D.C.), 65(10): 1277 – 1280. doi:10.1176/appi.ps.201300247.Goethals, S., Dierckx de Casterlé B., Gastmans, C. (2013). Nurses’ decision-making process in cases of physical restraint in acute elderly care: A qualitative study. Int J Nurs Stud, 50(5):603-12. doi:10.1016/j.ijnurstu.2012.10.006. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23123034Guzman-Parra, J., Aguilera Serrano, C., García-Sánchez, J. A., Pino-Benítez, I., Alba-Vallejo, M., Moreno-Küstner, B., & Mayoral-Cleries, F. 2016). Effectiveness of a multimodal intervention program for restraint prevention in an acute Spanish psychiatric ward. Journal of the American Psychiatric Nurses Association, 22(3), 233 – 241. doi:10.1177/107839031664 4767.Wieman, D. A., Camacho-Gonsalves, T., Huckshorn, K. A., & Leff, S. (2014). Multisite study of an evidence-based practice to reduce seclusion and restraint in psychiatric inpatient facilities. Psychiatric Services, 65(3), 345-351. doi:10.1176/appi.ps.201300210 LITERATURE REVIEW SUMMARY TABLE CitationBowers, L., James, K., Quirk, A., Simpson, A., Stewart, D., & Hodsoll, J. (2015). Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial. International Journal of Nursing Studies, 52(9), 1412 -1422. doi:10.1016/j. Type of StudyPrimary study Design Type Quantitative – cluster randomizedcontrolled trialFramework/TheoryThe Safewards model can effectively reduce the use of SR in psychiatric care. Setting31 psychiatric wards at 15 hospitals within 100 km of central London. Key Concepts/ VariablesIndependent variable/control condition:Implementationof a package of interventions directed at improving staff physical health (expected to have no impact on conflict and containment; Dependent variable/experimental condition: Implementation of the Safewards model interventions. FindingsRelative to the Control intervention, when conflict events occurred the Safewards intervention reduced the rate of conflict events by 15.0%.“The trial Intervention proved to be effective in reducing both conflict and containment.” Hierarchy of Evidence LevelLevel 2CitationBowers, L., Ross, J., Nijman, H., Muir-Cochrane, E., Noorthoorn, E., & Stewart, D. (2012). The scope for replacing seclusion with time out in acute Inpatient psychiatry in England. Journal of Advanced Nursing, 68(4), 826 – 835 10p. doi:10.1111/j. 1365-2648.2011.05 784.x. Type of StudyPrimary study DesignQualitative & quantitative – Retrospective case Notes review.Framework/TheoryIn psychiatric inpatients, how does the use of time out compare to the use of SR in managing patient aggression, and what causes the use of SR? Setting 84 acute psychiatric wards and psychiatric ICUs in 31 hospitals around London, UK between June 2009 andMarch 2010 Key Concepts/ VariablesVariables: “patients subjected to timeout or seclusion in the first 2 weeks of admission were compared to those who were not” “those who experienced more than one time-out orseclusion were compared with thoseexperiencing only one episode” Findings39 participants were secluded once or more during first 2 weeks of admission; 81 were subjected to time out once or more; time out was more likely to be used repeatedly with the same patient; “the most common start to a sequence of events leading to seclusion was aggressive behavior by the patient.”“Aggression was more prominent as a precursor of time-out than for seclusion.” Verbal aggression tended to result in time-out, while physical aggression was met with seclusion. Hierarchy of Evidence LevelLevel 2CitationGodfrey, J. L., McGill, A. C., Jones, N. T., Oxley, S. L., & Carr, R. M. (2014). Anatomy of a transformation: A systematic effort to reduce mechanical restraints at a state psychiatric hospital. Psychiatric Services (Washington, D.C.), 65(10): 1277 – 1280. doi:10.1176/appi.ps.201300247. Type of StudyPrimary study, DesignQuantitativeFramework/TheoryPolicy change and staff education or training in alternative techniques can reduce SR use. SettingA 398-bed state psychiatric hospital in North Carolina from September 1, 2009, to July 31, 2012 Key concepts/ VariablesIndependent variable: Implementation of interventions (staff training in de-escalation techniques and policy change).Dependent variable: Rate of mechanicalrestraint use FindingsCommitted leadership was found “essential for developing and implementing plans that reduce use of mechanical restraints”.“Monitoring the performance of the response team and requiring approval for use of mechanical restraint provided a level of accountability for staff actions and encouraged staff to follow the de-escalation principles” Hierarchy of Evidence LevelLevel 7CitationGuzman-Parra, J., Aguilera Serrano, C., García-Sánchez, J. A., Pino-Benítez, I., Alba-Vallejo, M., Moreno-Küstner, B., & Mayoral-Cleries, F. (2016). Effectiveness of a multimodal intervention program for restraint prevention in an acute Spanish psychiatric ward. Journal of the American Psychiatric Nurses Association, 22(3), 233 – 241. doi:10.1177/107839031664 4767. Type of StudyPrimary studyDesign:Quantitative – retrospective cohortFramework/TheoryMultimodal intervention can effectively reduce the use of mechanical restraints in psychiatric care. Setting42 bedacute psych wardof a universitygeneral hospitalin an urban areaof Spain over atwo-year period Key concepts/ VariablesIndependent variable: use ofIntervention programDependent variable: use or not of restraint during hospital stay. FindingsIn 2012 (non-intervention year), there were 164 episodes of restraint. In 2013 (implementation year), there were 85 episodes of restraint. The total percentage of restrained patients fell from 15.07% in 2012 to 9.74% in 2013 (a 35.37% decrease). Hierarchy of Evidence LevelLevel 4CitationWieman, D. A., Camacho-Gonsalves, T., Huckshorn, K. A., & Leff, S. (2014). Multisite study of an evidence-based practice to reduce seclusion and restraint in psychiatric inpatient facilities. Psychiatric Services, 65(3), 345-351. doi:10.1176/appi.ps.201300210 Type of Study Primary studyDesignQuantitative – quasi- experimental Framework/ TheoryImplementationof the 6Cs model will impact the use of SR in inpatient psychiatric care facilities. Setting43 inpatient psychiatric facilities in 8 states of the USA over a period of 4 years. Key concepts/ variables:Independent variable: facility and patient characteristics, implementation of 6CS model Dependent variables: Fidelity – the extent to which delivery of an intervention adheres to the protocol or program model originally developed.Sustainability – the extent to which a newly implemented treatment is maintained or institutionalized within a service setting’s ongoing, stable operations.Rates of S/R use Findingsa) Facilities that continued to implement changes, adding components, and adhering to the changes showed the greatest reduction in the percentage of patients secluded. b) Facilities that reached at least stable implementation rates showed reduced percentages of S/R use, S/R duration. c) Fidelity and sustainability at different facilities correlated with actual reduction of S/R use. Hierarchy of Evidence LevelLevel 3

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