Consumer Participation in Treatment and Recovery
Question:
Discuss about the Reducing Restrictive Interventions for Freedom and Dignity.
The Mental Health Act (MHA) was effected on 1st July 2014 in Victoria. This act was promulgated by the Victoria Government to protect the rights, freedom, dignity, and integrity of people suffering from mental illnesses. This Act not only protects the rights of mental health patients, but it also grants them the right to make medical decisions that affects their mental (Parliament of Victoria, 2014). Further, this Act encourages communication between doctors and consumers. Along with the responsibility of informing the patients about their illness, the doctors will also need to inform the family members and caregivers about the patients care plan (N. H. S. Confederation, 2018). Before the Act came into place, these responsibilities were not legally required of the practitioners and they could provide them upon their discretion.
The MHA encourages the consumers of mental health services to participate in decision making processes regarding their treatment, diagnoses, and recovery. Also, this act recognizes that mental consumers are people who have rights, and their integrity, dignity and human rights deserves respect and protection. It prevents corrupt practitioners from exploiting the patients. The acts put some more priority to minors suffering from mental illnesses. The importance of children’s safety, care and well-being is placed at the fore-front.
The doctors have the responsibility of providing educating and information to the consumers. A very fundamental provision is the emphasis on the importance of treatment and recovery procedures provided to the patients. The act stress that such services must ensure that no rights of the patient that are breached. The care and treatment provided to the patients are to be provided in a holistic approach focusing on recovery and must be individualized for every patient. A general approach should not be taken in the treatment for every patient.
From the past studies, some of these features have been found to be very important in the in concern for mental health services. For instance, the study of (Chan, Webber, & Hayward, 2013) analyzed the use of restrictive interventions on minors and young adults. The results of this study found that there is a great number of children who are subjected to restrictive interventions. Another study conducted by (Brady, Spittal, Brophy, & Harvey, 2017) to weigh the overall perception of the benefits of restrictive interventions among consumers. Despite the fact that there were a few reported benefits, very few patients love the experience. This study was part of the literatures that find no rationale in the use of restrictive interventions.
In the study of (Webber, McVilly, & Chan, 2011), restrictive interventions were being used as a strategy instead of a last resort. The interest of these authors for this study was inspired by their previous study that had shown that the use of restrictive interventions was very common (Webber, McVilly, Stevenson, & Chan, 2010). The authors undertook a study to confirm the perceived serious harm as the reason for the prevalence rates of cases in restrictive intervention. However, the conclusion of this study was that restrictive interventions were being used as health intervention strategy.
Regulation of Restrictive Interventions
Above all these reasons that demonstrates the best interest of MHA, the work of (McSherry, 2017) emphasize on the Convention on the Rights of Persons with Disabilities (CRPD). In article 3, the work of (McSherry, 2017) clarifies the issue of respect for individuals’ autonomy and inherent dignity and individual as explained in CRPD.
Restrictive interventions are regulated in part 6 of the MHA. With respect to mental health, restrictive interventions are certain medical procedures that limit or restrict a patient suffering from mental illness some rights such as the freedom of movement, speech, etc. Restrictive interventions could include other factors such as seclusion and isolation of the person, physical and mental restrains for the sake of treatment and recovery procedures (Tang, Liu, Zhang, & Zhang, 2018). In section 105, the law provide that restrictive interventions can only be used if all reasonable less restrictive methods fail.
Division 3 in part 6 of the act provides regulates issues of physical restraint. This is the use ofe physical or mechanical contact with a person in order to restrict their movement partially or completely. Section 113 of the Act provide that body restrain may be necessary where it would help in preventing harm to the patient or a different person. It can also be used for the purpose of administering treatment to the patient (Tang et al., 2018).
Division 2 of part 6 regulates the practice of seclusion in mental health services. According to (Mayers, Keet, Winkler, & Flisher, 2010), seclusion includes confinement or isolation of a patient in a supervised and secure manner in order to prevent the patient from harming others due to the mental illness they are suffering from. The provisions of section 110 provides that a mental health patient may be put to seclusion to prevent harm for him or other persons. However, section 111 deals with regulation of seclusion. Firstly, it decides the person who can authorize seclusion if it comes out of necessity that such patient would be secluded. The section provides that either an authorized psychiatrist or a registered medical professional or senior registered nurses in the case where an authorized psychiatrist is not available.
Sub-section (2) deals with situations where seclusion is authorized by registered medical practitioners or the senior registered nurse. This subsection requires that if any of these officers authorizes seclusion, they must notify the authorized psychiatrist who was not present to authorize seclusion. When subsection (2) is satisfied, then the authorized psychiatrist has a duty to examine the patient who was put to seclusion and determine whether the person would remain in seclusion or terminate it.
Further, subsection (4) deals with situations where an authorized psychiatrist can be absent to both authorize seclusion and examine it to very its necessity. In this section, the duty to determine the longevity of seclusion is put under the medical officer or the senior registered nurse. the authorized psychiatrist must ensure that a registered medical practitioner examines the person and determines whether the continued use of seclusion of the person is necessary as soon as practicable after the authorized psychiatrist is notified under subsection.
Physical Restraint
Section 112 deals with the care of the secluded person. This section directs medical professionals to clinically monitor patients put to seclusion. Monitoring should not be not take intervals that go beyond 15 minutes. Further, the authorised psychiatrist is designated to examine the secluded patient a until that psychiatrist is satisfied that the seclusion is necessary. The examination should not take intervals more than four hours.
Section 15 provides the guidelines when practitioners can use physical or bodily restraint without the need to seek authorization. Section 115 (b) provides that unauthorized restrictive interventions if professionals charged with giving authority are not available yet restrictive interventions is necessary at the moment. However, the same section under (3) requires the stop of the use of restrictive interventions if a senior officer charged with authorization finds it restrictive interventions unnecessary.
Under section 115(1a) the law allows registered nurses to use unauthorized bodily restraint when there is an urgency and the failure to use restrictive interventions would result to serious harm to either the patient or another person. Restrictive interventions are to be used on persons or patients suffering from mental illness for the sole purpose of treating and recovering them. They are not to be used for purposes such as sadistic entertainment, torture, information extraction, etc. The work of (Bowers et al., 2015) provides a conclusion that the use of restrictive interventions must be authorized by professionals, experts or institutions.
The persons responsible for authorizing the use of restrictive interventions can be: 1) a psychiatrist, who is authorized by the government or an organization to provide such an authorization, 2) A senior doctor or medical practitioner can also provide such an authorization in times of extreme emergency or if the authorized psychiatrist is unavailable at the time(Angell & Bolden, 2015). If a medical practitioner has provided the authorization, the authorized psychiatrist must be notified of this decision as soon as he or she is available. Once the psychiatrist is notified, it then becomes his or her responsibility to check the patient in order to decide the continuation of restrictive interventions or to stop them (Riding, 2016).
The Victorian Government has done extensive research on the use of restrictive interventions in mental health illness cases and has decided to bring forward the MHA in 2014 (Fletcher et al., 2017). The guidelines states that a mental health institution must only use restrictive interventions as a last resort and only when all other measures taken have failed. Restrictive interventions must in no way be a regular way of treating patients and must only be done in cases where there is no other option. The staff treating the mental health patients must observe the dignity of the patient. The staff treating the mental health patient must observe the rights of the patient. The staff must meet the legislative requirements.
In the state of Victoria, the types of restrictive interventions used are seclusion and physical restraint. There are various steps that have been taken to reduce restrictive intervention as guided by the MHA of 2014. The work of (McKenna, 2016) informs on various alternatives to restrictive interventions. The work names systemic service-based approaches six essential strategies. However, all these strategies stretch on the improvement of the leadership management to bring organization change. For instance, the work of (McKenna, 2016) advices on the use of data for informing the practice, a focus on the development of the workforce, use of trauma informed intervention and sensory modulation employment of the expertise who are specialist of lived experience in mental health and illnesses to work together with clinical staffs, and the use of debriefing techniques. These Victorian government has also proposed for the implementation of the initiatives. These plans that have been developed by medical institutions and help centers include numerous strategies to be implemented in order to successfully reduce the use of restrictive interventions across the state (Victoria Government, 2015).
Seclusion
Safewards is a medical model used to reduce restrictive interventions in many medical institutions around the world. The state of Victoria, Australia has successfully implemented this model throughout the state in an effort to reduce or completely eliminate the use of restrictive interventions (Cope Foundation, 2011). In an effort to prove the efficacy of Safewards, the study of (Fletcher et al., 2017) found that Safewards interventions were appropriate for use in mental health services and it is best option compared to seclusion. Also, the work of (Glasper, 2014) states that the implementation of Safewards has been successful in reducing the use of restrictive interventions
The Victorian Government, along with the establishment of the MHA, has developed a framework to reduce the use of restrictive interventions. According to (Health Vic, 2013), the framework provide a safe environment where mental health patients can receive mental health help and it also helps the mental health professionals in planning and designing services for better reduction and where possible achieve complete elimination of the use restrictive interventions.
According to (Health Vic, 2013), the practice of reducing restrictive i.e restraints and seclusions, are essential in providing mental health assistances that are generally safe to all patients, visitors, carers, health professional. The framework advices that restraints and seclusions cannot be used as the main focus on mental health. In agreement with this framework, the work of (Vollmer, et al., 2011) states that all possible measures and options of controlling or calming the patient should be taken before engaging any restrictive interventions to be used. According to (Health Vic, 2013), there is evidence that has shown that restrictive interventions can retraumatize consumers as part of the past experiences of traumatization, and such can impede the proper development a trusting professional-patient relationships.
According to (Department of Health, 2013), the framework principles aims to provide a safe environment for all, and this environment was underpinned by wide-range of reviews of restrictive interventions research. The report states that the framework encompass three core principles which are derived from the believe that recovery is all about empowering people to formulate their own decisions and their involvement in self-care. Therefore, the aim of restrictive intervention is to create a collaborative environment. Secondly, the framework recognizes that restrictive intervention particularly seclusion and restraints put the rights, freedom, physical and psychological safety of a person in jeopardy. Lastly, the board has to manage and monitor the use of restrictive intervention.
The three principles in the framework advice that the reducing restrictive interventions should be everyone’s business where all he key stakeholders (people with lived experiences, carers, service staff) should take their roles in providing, designing, and implementation a safe environment. It also advices on the need for respect and dignity for the people with lived experiences together with their carers and staff. This principle is explained in detail in the work of (Clark, Shurmer, Kowara, & Nnatu, 2017) where the respect for the should not be ignored due to their behaviors caused by the mental state. Further, the organization of the service environment should be made to ensure that safety it promotes safety and wellbeing for everyone involved. The management of difficult and challenging behaviors should feature acts of humanity, decency, and respect. In overall, the principles are explained as encompassing capability, care approach and enablers.
Studies on Restrictive Interventions
The principle of capabilities of services refers to how mental health services should focus their capabilities in reducing restrictive practices (Department of Health, 2013). This principle focuses on four main areas. The first one is on mental health leadership and accountabilities. In this area, the principle emphasizes on setting targets for the develop methods. These methods should be aimed at facilitation of maximum accountability and changes in the practices. The next area that this principle looks at is the mental health systems where it emphasizes on the support for the delivery of actionable plans, clarity of the health service’s in their vision in the implementation of the reducing restrictive interventions. The principle also emphasizes on the developments that support the consumer’s self-determination. i.e, respect for person’s rights, wishes and plans for the recovery. Lastly, this principle emphasizes on the copiability of the workforce in executing the roles for clarity, understanding and the application of practices.
The second principle is summarized under care approaches (Department of Health, 2013). The framework recognizes that approaches to quality care are integral to the health organizational capabilities. The framework advices for a focus on three main care approaches. One of these is the recovery-oriented approach. According to the A recovery approach should focus on promoting the consumer’s choice, agency and independency of the management. Recovery approaches should encourage the consumer’s self-management and self-determination in matters of mental health. They should also be tailored, strengths-based and personalized towards unique needs, circumstances, and preferences. In overall, they are holistic approach aimed at empowering the individual.
The last principle emphasizes on the enablers (Department of Health, 2013). The framework recognizes four enablers in the organizations effort in reducing restrictive interventions. The first one is a focus on cultural system where the organization culture and systems should be aligned towards its objective in reducing restrictive interventions. The second enabler emphasizes on provision of a healthy environment where the physical settings, social dynamics, culture, and behavioral patterns demonstrate an environment that is calm, safety of the wards, and therapeutic safety. The third enabler is the anticipation of needs and management of escalations. This one emphasizes on professional support for patients and the identification and timely response to anxiety, conflicts and acute arousals. The fourth enabler emphasize on the evaluation and quality assurances which are focused on the improvement of the services in reduction of restrictive interventions.
References
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Bowers, 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. https://doi.org/10.1016/j.ijnurstu.2015.05.001
Brady, N. S., Spittal, M. J., Brophy, L. M., & Harvey, C. A. (2017). Patients’ Experiences of Restrictive Interventions in Australia: Findings From the 2010 Australian Survey of Psychosis. Psychiatric Services, 68(9), 966–969. https://doi.org/10.1176/appi.ps.201600300
Chan, J., Webber, L. S., & Hayward, B. (2013). Examining the Use of Restrictive Interventions in Respite Services in an Australian Jurisdiction. Psychiatry, Psychology and Law, 20(6), 921–931. https://doi.org/10.1080/13218719.2013.770357
Clark, L. L., Shurmer, D. L., Kowara, D., & Nnatu, I. (2017). Reducing restrictive practice: Developing and implementing behavioural support plans. British Journal of Mental Health Nursing, 6(1), 23–28. https://doi.org/10.12968/bjmh.2017.6.1.23
Cope Foundation. (2011). Guidelines for the Prevention of/Use of Restrictive Interventions. Fedvol.Ie. Retrieved from https://www.fedvol.ie/_fileupload/Quality%20&%20Standards/Policies%20for%20Website/Policy%20for%20Prevention%20of%20use%20of%20Restrictive%20Interventions.pdf
Department of Health. (2013). Providing a safe environment for all: Framework for reducing restrictive interventions. Mental Health, Drugs and Regions Division, Department of Health, Victorian Government Melbourne, Vic.
Fletcher, J., Spittal, M., Brophy, L., Tibble, H., Kinner, S., Elsom, S., & Hamilton, B. (2017). Outcomes of the Victorian Safewards trial in 13 wards: Impact on seclusion rates and fidelity measurement. International Journal of Mental Health Nursing, 26(5), 461–471. https://doi.org/10.1111/inm.12380
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Mayers, P., Keet, N., Winkler, G., & Flisher, A. J. (2010). Mental health service users’ perceptions and experiences of sedation, seclusion and restraint. International Journal of Social Psychiatry, 56(1), 60–73.
McKenna, B. (2016). Reducing Restrictive Interventions. Journal of Forensic Nursing, 12(2), 47–48. https://doi.org/10.1097/jfn.0000000000000108
McSherry, B. (2017). Regulating seclusion and restraint in health care settings: The promise of the Convention on the Rights of Persons with Disabilities. International Journal of Law and Psychiatry, 53, 39–44. https://doi.org/10.1016/j.ijlp.2017.05.006
H. S. Confederation. (2018). Positive and proactive care: reducing the need for restrictive interventions. Nhsconfed.Org. Retrieved from https://www.nhsconfed.org/news/2014/04/positive-and-proactive-care-reducing-the-need-for-restrictive-interventions
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Riding, T. (2016). Exorcising restraint: reducing the use of restrictive interventions in a secure learning disability service. Journal of Intellectual Disabilities and Offending Behaviour, 7(4), 176–185. https://doi.org/10.1108/jidob-06-2016-0007
Tang, Y., Liu, C., Zhang, Z., & Zhang, X. (2018). Effects of prescription restrictive interventions on antibiotic procurement in primary care settings: a controlled interrupted time series study in China. Cost Effectiveness and Resource Allocation, 16(1). https://doi.org/10.1186/s12962-018-0086-y
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Webber, L. S., McVilly, K. R., & Chan, J. (2011). Restrictive Interventions for People with a Disability Exhibiting Challenging Behaviours: Analysis of a Population Database. Journal of Applied Research in Intellectual Disabilities, 24(6), 495–507. https://doi.org/10.1111/j.1468-3148.2011.00635.x
Webber, L. S., McVilly, K. R., Stevenson, E., & Chan, J. (2010). The use of restrictive interventions in Victoria, Australia: Population data for 2007–2008. Journal of Intellectual & Developmental Disability, 35(3), 199–206. https://doi.org/10.3109/13668250.2010.489038
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