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OBJECTIVE: Post-coercion review is increasingly regarded as a mean to reduce the negative consequences of coercive interventions, including the development of posttraumatic symptoms. However, the efficacy of this intervention in preventing posttraumatic symptoms or PTSD has not been sufficiently studied. The objective of this study is to examine the influence of a single, standardized post-coercion review session on the development or exacerbation of PTSD symptoms in patients with psychotic disorders. METHODS: In a multi-center, two-armed, randomized controlled trial, patients who experienced coercive interventions during current hospitalization were either randomized to standard treatment or an intervention group receiving a guideline-based, standardized reflecting review session. Factorial MANCOVA and subsequent ANCOVAs investigated the effects of the post-coercion reflecting review session on post-traumatic symptoms as measured by the subscales of the Impact of Events Scale-Revised (IES-R). Similarly, the effect of the intervention on the intensity of the peritraumatic reactions measured by the Peritraumatic Distress Inventory (PDI) was analyzed by conducting a factorial ANCOVA. RESULTS: N = 82 patients were included in an intention-to-treat analysis. MANCOVA and post hoc ANCOVAs revealed a significant main effect of the intervention for the IES-R subscales intrusion and hyperarousal, when controlling for levels of peritraumatic distress, whereby intervention group participants presented lower respective mean scores. There was no significant difference regarding the intensity of the peritraumatic reaction. CONCLUSION: Standardized post-coercion review contributes to a reduction of the burden of PTSD symptoms in patients with psychotic disorders experiencing coercive interventions in acute settings and shall be recommended as a measure of trauma-informed care. The trial was registered at ClinicalTrials.gov (ID NCT03512925) on 01/30/2018 (retrospectively registered).

PROBLEM: Aggressive behavior is common on psychiatric inpatient units. Seclusion and restraint interventions to manage patients' aggressive behavior may have the consequence of being traumatizing for patients. Pediatric psychiatric patients' perspective on the use of seclusion and restraint interventions is not present in the literature. METHODS: This hermeneutic nursing research study asked the question, "How might we understand children's experiences of seclusion and restraints on an inpatient psychiatric unit?" Four past pediatric psychiatric inpatients shared their hospitalization experiences that occurred within the previous year when they were 10 years old. The texts of the research interviews were compared to Attachment Theory for a deeper understanding of the meaning of the message. FINDINGS: Participants commonly described experiences with seclusion and restraints as feeling trapped and alone in a dark room. They recommended the nurses step into the room with them to help them heal. Interpretively, the rooms on inpatient units could be considered as actual and metaphorical spaces of possible harm or healing. CONCLUSION: The participant's voices expand understanding of nurse's use of discernment at the doorway of a patient room to ensure the most therapeutic care is provided to the patient in these spaces through a secure nurse-patient relationship.

WHAT IS KNOWN ON THE SUBJECT?: Seclusion is a harmful and traumatising intervention for people accessing mental health services. People who are subject to seclusion in inpatient mental health services often first experience this within the first 24 h following admission. There is limited research examining how recent contact with services impacts the likelihood of seclusion when people are admitted to inpatient services. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Males, Māori and Pasifika experience higher rates of seclusion within the first 24 h following inpatient admission. People perceived by clinicians as overactive, aggressive, disruptive or agitated are seven times more likely to be secluded within the first 24 h. People referred from police or justice services are three times more likely to be secluded within the first 24 h. People who had frequent contact with community mental health services prior to inpatient admission were less likely to be secluded. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The first 24 h of inpatient admission is a critical focus for eliminating the use of seclusion. Initial interactions with people recently admitted should focus on nurturing relationships and reducing distress. Mental health staff should consider the person's cultural needs, referral pathway, recent service contact and baseline ratings on the Health of the Nation Outcomes Scales (HoNOS) when working proactively to prevent the use of seclusion in the first 24 h following admission. Strengthening the focus on nurturing relationships, cultural understanding and non-coercive de-escalation approaches requires leadership support and strategic workforce development. ABSTRACT: Introduction People who experience seclusion in inpatient mental health services often do so within the first 24 h following admission. There is limited research examining the potential contributing factors, particularly recent contact with services. Aim/Question To identify factors associated with seclusion within the first 24 h following admission into acute inpatient mental health services. Method A retrospective analysis was undertaken using routinely collected data from Aotearoa New Zealand mental health services. Results A higher likelihood of seclusion within the first 24 h following admission was associated with: males, Māori, Pasifika, referrals from police/justice services, inpatient transfers, recent contact with crisis assessment teams and clinician perceptions of aggression, problematic substance use, cognitive problems and hallucinations or delusions. Recent contact with community mental health services was associated with a lower likelihood. Discussion People's cultural needs, referral pathway, recent service contact and HoNOS scores should be considered when working to prevent the use of seclusion in the first 24 h following admission. Implications for Practice The first 24 h following inpatient admission is a critical period for preventing the use of seclusion. Nurturing relationships, cultural understanding and use of non-coercive de-escalation approaches can support better outcomes for people recently admitted.

BACKGROUND: There is a lack of studies exploring the performance of Transformers-based language models in common risks assessment among psychiatric inpatients. We aim to develop a scalable risk assessment model using multidimensional textualized data and test the stability, robustness, and benefit of this approach. METHODS: In this real-world cohort study, a deep learning language model was developed and validated using first hospitalized cases diagnosed with schizophrenia, bipolar disorder, and depressive disorder between January 2016 and March 2023 in three hospitals. The algorithm was externally validated on an independent testing cohort comprising 1180 patients. A total of 140 features, including first medical records (FMR), laboratory examinations, medical orders, and psychological scales, were assessed for analysis. The outcomes were short- and long-term impulsivity (STI and LTI), risk of suicide (STSS and LTSS), and need of physical restraint (STPR and LTPR) assessed by qualified nurses or clinicians. Analysis was carried out between August 2024 and June 2024. Models with different architectures and input settings were compared with each other. The area under the receiver operating characteristic curve (AUROC) was used to assess the primary performance of models. The clinical utility was determined by the net benefit under Youden's threshold. RESULTS: Of 7451 patients included in this study, 2982 (47.6%) were male, and the median (interquartile range) age was 42 (28-57) years. The overall incidence of outcomes was 635 (8.5%), 728 (10.5%), 659 (8.8%), 803 (10.8%), 588 (7.9%), and 728 (9.8%) for STPR, LTPR, STSS, LTSS, STI, and LTI, respectively. The multitask semi-structured Transformers-based language (SSTL) model showed more promising AUROCs (STPR: 0.915; LTPR: 0.844; STSS: 0.867; LTSS: 0.879; STI: 0.899; LTI: 0.894) in the prediction of these outcomes than single-tasked or multimodal language models and traditional structured data models. Combining FMR with other data from electronic health records led to significant improvements in the performance and clinical utility of SSTL models based on demographic, diagnosis, laboratory tests, treatment, and psychological scales. CONCLUSIONS: The SSTL model shows potential advantages in prognostic evaluation. FMR is a strong predictor for common risks prediction and may benefit other tasks in psychiatry with minimum requirements for data and data processing.

Medically unstable young people with anorexia nervosa or atypical anorexia nervosa, are admitted to the adolescent medical ward at the reporting institution for nutritional rehabilitation. If meals are refused a nasogastric tube may be needed. At times restraint is used to ensure the required feeds are administered. This is an ethically complex and distressing dilemma for all involved and can result in long-term trauma for young people. The aim of this project was to establish a profile of young people with anorexia nervosa or atypical anorexia nervosa who require restraint for nasogastric tube insertion and/or feeding in the acute care paediatric setting and to understand the extent of restraint events occurring. We undertook a retrospective audit of inpatients admitted to the adolescent medical ward at a quaternary pediatric hospital in Melbourne, Australia, between 2021 and 2023, for the treatment of anorexia nervosa or atypical anorexia nervosa. Data points were agreed by multidisciplinary stakeholders and were collected from the institution’s electronic medical record. Data were analysed using descriptive statistics. Of the 217 young people admitted, 23 (11%) had documented physical restraint for nasogastric tube feeding. Mental health comorbidities, neurodivergence, and social or behavioural complexity were higher in the young people who required feeding restraint as compared to those that did not. Of note, 15 (65%) of young people who were restrained for feeds had a diagnosis of autism, or a clinical note in their medical record indicating possible autism. Young people in our institution admitted to the adolescent medical ward with anorexia nervosa or atypical anorexia nervosa who are restrained for feeding have a more complex clinical, social and behavioural profile than those who do not require restraint. Care and treatment tailored to the individual, sensitive to neurodivergence, encourages clinicians to consider the young person they are treating to reduce or prevent restraint and to inform a restraint approach that mitigates iatrogenic harm. Young people who are inpatients on a medical ward when critically unwell with anorexia may require a nasogastric tube for nutrition when oral intake is inadequate. If the young person requires a nasogastric tube but refuses, they may be restrained for this urgent medical treatment. Those who are more likely to be restrained for nasogastric tube feeding might be identified through their more complex social, behavioural and clinical profiles. Importantly, there is an overrepresentation of those with a diagnosis of autism or clinical suspicion of autism, experiencing restraint for feeding via a nasogastric tube. For these young people, individualised care, sensitive to neurodivergence for an admission for medical stabilisation, may reduce the need for restraint to feed and minimise potential harm due to medical treatment.

BACKGROUND: Stakeholders worldwide increasingly acknowledge the need to address coercive practices in mental healthcare. Options have been described and evaluated in several countries, as noted recently in major policy documents from the World Health Organization (WHO) and World Psychiatric Association (WPA). The WHO's QualityRights initiative promotes human rights and quality of care for persons with mental health conditions and psychosocial disabilities. A position statement from the WPA calls for implementation of alternatives to coercion in mental healthcare. AIMS: We describe the engagement of both the WHO and WPA in this work. We discuss their mutual aim to support countries in improving human rights and quality of care, as well as the differences between these two organisations in their stated goals related to coercion in mental healthcare: the WHO's approach to eliminate coercion and the WPA's goal to implement alternatives to coercion. METHOD: We outline and critically analyse the common ground between the two organisations, which endorse a similar range of rights-based approaches to promoting non-coercive practices in service provision, including early intervention in prevention and care and other policy and practice changes. RESULTS: Advocacy and action based on an agreed need to find practical solutions and advances in this area have the power to build consensus and unify key actors. CONCLUSIONS: We conclude that persons with lived experience, families, mental health professionals and policy makers are now coming together in several parts of the world to work toward the common goals of improving quality, promoting human rights and addressing coercion in mental health services.

INTRODUCTION: Physical restraints (PR) are regularly used in acute care settings, although evidence for their effectiveness and safety (eg, for prevention of falls) is lacking. Their use is associated with adverse events, such as decreased mobility and injuries for patients. We developed a complex intervention to prevent PR in acute care settings according to the UK Medical Research Council Framework, and investigated the feasibility. The intervention comprised the qualification of key nurses as multipliers and a short interprofessional information session. The intervention has proven to be feasible. It also became apparent that further development of the intervention and the study procedures is necessary. Therefore, this study aims to refine and pilot the complex intervention. Furthermore, the objective of this pilot study is to improve study procedures. METHODS AND ANALYSIS: In a preparatory phase, we will conduct focus groups and individual interviews with the target groups to explore the possibilities for adaption of the intervention and implementation strategies. Subsequently, a cluster-randomised controlled trial with a 6-month follow-up period will be conducted. It is planned to recruit eight general hospitals in Germany (area of Halle (Saale) and Leipzig) with 28 wards and 924 patients per observation period (2772 overall). Primary outcome is the proportion of patients with at least one PR after 6 months. Data will be collected by direct observation over a period of seven consecutive days and three times a day. Secondary outcomes are falls, interruptions in therapy and prescription of psychotropic medication. A comprehensive process evaluation will accompany the study. ETHICS AND DISSEMINATION: The Ethics committee of the Medical Faculty of the University of Halle (Saale) approved the study protocol. Results will be published in a peer-reviewed journal and presented at conferences. Study information and additional material will be freely available on an already existing website. TRIAL REGISTRATION NUMBER: DRKS00027989.

Background: Nurses comprise the largest component of the health workforce worldwide and numerous models of workforce allocation and profile have been implemented. These include changes in skill mix, grade mix or qualification mix, staff‐allocation models, staffing levels, nursing shifts, or nurses’ work patterns. This is the first update of our review published in 2011. Objectives: The purpose of this review was to explore the effect of hospital nurse‐staffing models on patient and staff‐related outcomes in the hospital setting, specifically to identify which staffing model(s) are associated with: 1) better outcomes for patients, 2) better staff‐related outcomes, and, 3) the impact of staffing model(s) on cost outcomes. Search methods: CENTRAL, MEDLINE, Embase, two other databases and two trials registers were searched on 22 March 2018 together with reference checking, citation searching and contact with study authors to identify additional studies. Selection criteria: We included randomised trials, non‐randomised trials, controlled before‐after studies and interrupted‐time‐series or repeated‐measures studies of interventions relating to hospital nurse‐staffing models. Participants were patients and nursing staff working in hospital settings. We included any objective reported measure of patient‐, staff‐related, or economic outcome. The most important outcomes included in this review were: nursing‐staff turnover, patient mortality, patient readmissions, patient attendances at the emergency department (ED), length of stay, patients with pressure ulcers, and costs. Data collection and analysis: We worked independently in pairs to extract data from each potentially relevant study and to assess risk of bias and the certainty of the evidence. Main results: We included 19 studies, 17 of which were included in the analysis and eight of which we identified for this update. We identified four types of interventions relating to hospital nurse‐staffing models: introduction of advanced or specialist nurses to the nursing workforce; introduction of nursing assistive personnel to the hospital workforce; primary nursing; and staffing models. The studies were conducted in the USA, the Netherlands, UK, Australia, and Canada and included patients with cancer, asthma, diabetes and chronic illness, on medical, acute care, intensive care and long‐stay psychiatric units. The risk of bias across studies was high, with limitations mainly related to blinding of patients and personnel, allocation concealment, sequence generation, and blinding of outcome assessment. The addition of advanced or specialist nurses to hospital nurse staffing may lead to little or no difference in patient mortality (3 studies, 1358 participants). It is uncertain whether this intervention reduces patient readmissions (7 studies, 2995 participants), patient attendances at the ED (6 studies, 2274 participants), length of stay (3 studies, 907 participants), number of patients with pressure ulcers (1 study, 753 participants), or costs (3 studies, 617 participants), as we assessed the evidence for these outcomes as being of very low certainty. It is uncertain whether adding nursing assistive personnel to the hospital workforce reduces costs (1 study, 6769 participants), as we assessed the evidence for this outcome to be of very low certainty. It is uncertain whether primary nursing (3 studies, > 464 participants) or staffing models (1 study, 647 participants) reduces nursing‐staff turnover, or if primary nursing (2 studies, > 138 participants) reduces costs, as we assessed the evidence for these outcomes to be of very low certainty. Authors' conclusions: The findings of this review should be treated with caution due to the limited amount and quality of the published research that was included. We have most confidence in our finding that the introduction of advanced or specialist nurses may lead to little or no difference in one patient outcome (i.e. mortality) with greater uncertainty about other patient outcomes (i.e. readmissions, ED attendance, length of stay and pressure ulcer rates). The evidence is of insufficient certainty to draw conclusions about the effectiveness of other types of interventions, including new nurse‐staffing models and introduction of nursing assistive personnel, on patient, staff and cost outcomes. Although it has been seven years since the original review was published, the certainty of the evidence about hospital nurse staffing still remains very low.

OBJECTIVE: Physical healthcare has dominated the patient safety field; research in mental healthcare is not as extensive but findings from physical healthcare cannot be applied to mental healthcare because it delivers specialised care that faces unique challenges. Therefore, a clearer focus and recognition of patient safety in mental health as a distinct research area is still needed. The study aim is to identify future research priorities in the field of patient safety in mental health. DESIGN: Semistructured interviews were conducted with the experts to ascertain their views on research priorities in patient safety in mental health. A three-round online Delphi study was used to ascertain consensus on 117 research priority statements. SETTING AND PARTICIPANTS: Academic and service user experts from the USA, UK, Switzerland, Netherlands, Ireland, Denmark, Finland, Germany, Sweden, Australia, New Zealand and Singapore were included. MAIN OUTCOME MEASURES: Agreement in research priorities on a five-point scale. RESULTS: Seventy-nine statements achieved consensus (>70%). Three out of the top six research priorities were patient driven; experts agreed that understanding the patient perspective on safety planning, on self-harm and on medication was important. CONCLUSIONS: This is the first international Delphi study to identify research priorities in safety in the mental field as determined by expert academic and service user perspectives. A reasonable consensus was obtained from international perspectives on future research priorities in patient safety in mental health; however, the patient perspective on their mental healthcare is a priority. The research agenda for patient safety in mental health identified here should be informed by patient safety science more broadly and used to further establish this area as a priority in its own right. The safety of mental health patients must have parity with that of physical health patients to achieve this.