Can Psychiatric Units Function Without Restraints? Italy Says Yes

A new study reveals that psychiatric units in Italy can effectively operate without restraints, paving the way for more humane mental health treatment.

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A new article published in Healthcare finds that General Hospital Psychiatric Units (GHPUs) in Italy can be safely and effectively run without restraints.

The current research, headed by Raffaella Pocobello of the Institute of Cognitive Sciences and Technologies, reports that restraints can be eliminated or significantly reduced through systematic procedures and risk management training emphasizing reduced coercive measures. The authors write:

“Despite these services being considered a minority of the 323 Italian GHPUs, our analysis demonstrates the feasibility and ethical alignment of operating without restraints. Specifically, our research documented the existence of 14 GHPUs in Italy that reported zero restraint episodes during 2022. Furthermore, 10 GHPUs are committed to reaching the same objective and, in most cases, have obtained encouraging results.”

The goal of the current research was to examine ‘no restraint’ committed GHPUs in Italy. The authors aimed to describe the experiences of these GHPUs, identify if different ‘no restraints’ models were being employed, identify organizational characteristics of ‘no restraint’ GHPUs, and provide an overview of these facilities.

One author, Giovanni Rossi, developed an initial survey to collect data from GHPUs. This survey was refined by representatives from members of ‘Club SPDC No Restraint,’ a group of GHPUs committed to reducing/eliminating the use of restraints in psychiatric settings. The survey then went through a final revision with experts on mental health services, survey methodology, and statistical analysis from the Institute of Cognitive Sciences and Technologies.

The final version of the survey contained 60 questions covering informant identification, facility-specific data, data on restraint utilization, infrastructure, staffing details, activities, monitoring protocols, catchment area, and departmental organization. The survey also included a section with an open-ended invitation for any additional comments.

Rossi, president of Club SPDC No Restraint and author of the current work, emailed representatives from the 24 GHPU members with an invitation to participate in the survey. Between April and June 2023, all 24 GHPUs that were invited completed the study.

The participating GHPUs had service areas that included 108,000 to 780,000 people, with an average service area of 296,710. 20 of 24 GHPUs operated under a health authority, one operated under a hospital organization, and 3 were a part of ‘other’ organizations such as university hospitals.

The surveyed GHPUs had between 4 and 24 beds, averaging 12.6. Most of the GHPUs (22 of 24) had double rooms, and 18 had at least one single room. More than half used room structures other than single or double. 19 of 24 GHPUs included an alarm bell in each room, and 18 of 24 had bathrooms attached to each room.

All the surveyed GHPUs had a living area that included a TV. 23 of 24 had a dining area. 18 of 24 provided service users with a smoking area. 9 of 24 had a drink dispenser, 7 of 24 had no drink dispenser but did have another way for service users to get drinks (such as a cafeteria), and 8 of 24 had no drink dispenser and no other means for getting drinks.

Nine of the 24 GHPUs had an armored door leading to the unit. Sixteen of 24 did not use cameras, and five of the eight that did use cameras only had them in specific rooms. Eighteen of 24 had gardens or some outside space available for service users. In 12 of the 18 GHPUs that had outside space available to service users, that space was exclusive to the GHPU ward; the remaining six shared outside space with other wards.

14 of the 24 GHPUs that completed the survey did not use restraints at all in 2022. The 10 GHPUs that used restraints in 2022 did so between 2 and 43 times, with an average of 4.5. The authors note that with the exception of 1 GHPU that used restraints 43 times in 2022, the ten members of ‘Club SPDC No Restraint’ that used restraints in 2022 did so as an “exceptional event” rather than a current practice.

In total, these 10 GHPUs used restraints 101 times in 2022. 73% of restraint use lasted less than 24 hours. The shortest restraint was 10 hours, and the longest was 14.5 days. 9 of the 10 GHPUs that used restraints in 2022 provided the constant presence of staff during the length of the restraint and initiated an audit of the event. All 10 GHPUs that used restraints kept records of such uses; 7 had procedures in place to limit the use of mechanical restraints, and 5 had procedures to reduce the risk and duration of restraints when they were used.

All the surveyed GHPUs employed medical doctors and nurses. Between 1 and 14 doctors were employed, with a median of 4. Between 9 and 29 nurses were employed, with a median of 14.5. 22 of the 24 GHPUs employed care workers, 11 employed psychologists, seven employed psychiatric rehabilitation technicians, and seven employed social workers. 23 of 24 GHPUs had a psychiatrist present or on call during night shifts. Medical doctors and nurses were typically present in these facilities during day and night shifts. When psychologists and social workers were available at a facility, it was typically only during the day shift.

Service users at the 24 GHPUs surveyed in the current research spent between 7 and 1682 days involuntarily committed to these facilities, with an average of 379.81 days. On average, 15.4% of the length of a service user’s stay in these facilities was involuntary.

23 of 24 GHPUs kept records of staff injuries due to service user aggression. 14 of 24 had computerized medical, nursing, and therapy records. 22 of 24 had a procedure in place for emergency room consultations and admissions. 19 of 24 had a procedure in place for risk management around service user aggression. 9 of 24 admitted more service users than they had registered beds.

All the facilities surveyed in the current research allowed service users to keep personal items such as phones, and half allowed service users to go out alone. Most GHPUs employed individualized care plans (22 of 24) and had private areas where therapy took place (20 of 24). Half of the GHPUs had procedures in place with local police departments in case of emergencies and involuntary admissions. 19 of 24 had a training program for staff on aggression risk management.

Most facilities using ‘no restraint’ policies (22 of 24) in Italy are located in the North and Central regions of the country. All ‘no-restraint’ facilities in the current research were located in small cities. The authors note that there are 0 ‘no-restraint’ facilities in metropolitan areas of Italy. The current work found that GHPUs with a ‘no-restraint’ policy were more likely to have structured procedures for risk management and outcome assessments. The current work also found a link between gardens and outside spaces accessible exclusively to psychiatric service users and the increased use of restraints.

The authors suggest that this connection may be due to the segregating nature of these spaces, which may exacerbate service users’ feelings of confinement and frustration.

The authors acknowledge several limitations to the current work. They only looked at physical restraint and did not collect data on the use of drugs to restrain service users. The study design excludes the ability to make causal inferences, meaning the authors cannot tell if observed policies cause less restraint use. The current research relied on a self-report survey, which means responses could be biased. The results of the current work are likely not generalizable outside Italy.

The World Health Organization has reported that the use of restraints in mental health settings is “far too common.” Past research has found that physical restraints can have harmful and long-lasting consequences for service users. Past research has also found racial and gender-based bias in the use of restraints in psychiatric facilities.¬†One study found that something as simple as redecorating psychiatric hospitals can lead to an 82% reduction in the use of restraints and seclusion.

 

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Pocobello, R.; Camilli, F.; Rossi, G.; Dav√¨, M.; Corbascio, C.; Tancredi, D.; Oretti, A.; Bonavigo, T.; Galeazzi, G.M.; Wegenberger, O.; et al. No-Restraint Committed General Hospital Psychiatric Units (SPDCs) in Italy‚ÄĒA Descriptive Organizational Study. Healthcare 2024, 12, 1104. https://doi.org/10.3390/ healthcare12111104 . (Link)

4 COMMENTS

  1. WOW! A lot of data here. I wonder about crisis intervention training among the Italian caregivers. I have used crisis intervention training for the last 40 years in the USA with favorable results. Could the author explain techniques that were helpful in reducing restraint events?

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  2. “One study found that something as simple as redecorating psychiatric hospitals can lead to an 82% reduction in the use of restraints and seclusion.”

    You mean us interior designers are not “irrelevant to reality,” as my psychiatrist and psychologist believed? Oh, that’s right, my psychiatrist’s listening skills were so well honed, he had delusions that being an interior designer was the same thing as being a “graphic designer,” according to my medical records.

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