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      Patients' experiences of assessment and detention under mental health legislation: systematic review and qualitative meta-synthesis


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          Understanding patient experiences of detention under mental health legislation is crucial to efforts to reform policy and practice.


          To synthesise qualitative evidence on patients' experiences of assessment and detention under mental health legislation.


          Five bibliographic databases were searched, supplemented by reference list screening and citation tracking. Studies were included if they reported on patient experiences of assessment or detention under mental health legislation; reported on patients aged 18 years or older; collected data using qualitative methods; and were reported in peer-reviewed journals. Findings were analysed and synthesised using thematic synthesis.


          The review included 56 papers. Themes were generally consistent across studies and related to information and involvement in care, the environment and relationships with staff, as well as the impact of detention on feelings of self-worth and emotional state. The emotional impact of detention and views of its appropriateness varied, but a frequent theme was fear and distress during detention, including in relation to the use of force and restraint. Where staff were perceived as striving to form caring and collaborative relationships with patients despite the coercive nature of treatment, and when clear information was delivered, the negative impact of involuntary care seemed to be reduced.


          Findings suggest that involuntary in-patient care is often frightening and distressing, but certain factors were identified that can help reduce negative experiences. Coproduction models may be fruitful in developing new ways of working on in-patient wards that provide more voice to patients and staff, and physical and social environments that are more conducive to recovery.

          Declaration of interest


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          Most cited references91

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          Trauma-informed or trauma-denied: Principles and implementation of trauma-informed services for women

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            Safewards: a new model of conflict and containment on psychiatric wards

            Accessible summary Rates of violence, self-harm, absconding and other incidents threatening patients and staff safety vary a great deal by hospital ward. Some wards have high rates, other low. The same goes for the actions of staff to prevent and contain such incidents, such as manual restraint, coerced medication, etc. The Safewards Model provides a simple and yet powerful explanation as to why these differences in rates occur. Six features of the inpatient psychiatric system have the capacity to give rise to flashpoints from which adverse incidents may follow. The Safewards Model makes it easy to generate ideas for changes that will make psychiatric wards safer for patients and staff. Abstract Conflict (aggression, self-harm, suicide, absconding, substance/alcohol use and medication refusal) and containment (as required medication, coerced intramuscular medication, seclusion, manual restraint, special observation, etc.) place patients and staff at risk of serious harm. The frequency of these events varies between wards, but there are few explanations as to why this is so, and a coherent model is lacking. This paper proposes a comprehensive explanatory model of these differences, and sketches the implications on methods for reducing risk and coercion in inpatient wards. This Safewards Model depicts six domains of originating factors: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. These domains give risk to flashpoints, which have the capacity to trigger conflict and/or containment. Staff interventions can modify these processes by reducing the conflict-originating factors, preventing flashpoints from arising, cutting the link between flashpoint and conflict, choosing not to use containment, and ensuring that containment use does not lead to further conflict. We describe this model systematically and in detail, and show how this can be used to devise strategies for promoting the safety of patients and staff.
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              Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial

              Background Acute psychiatric wards manage patients whose actions may threaten safety (conflict). Staff act to avert or minimise harm (containment). The Safewards model enabled the identification of ten interventions to reduce the frequency of both. Objective To test the efficacy of these interventions. Design A pragmatic cluster randomised controlled trial with psychiatric hospitals and wards as the units of randomisation. The main outcomes were rates of conflict and containment. Participants Staff and patients in 31 randomly chosen wards at 15 randomly chosen hospitals. Results For shifts with conflict or containment incidents, the experimental condition reduced the rate of conflict events by 15% (95% CI 5.6–23.7%) relative to the control intervention. The rate of containment events for the experimental intervention was reduced by 26.4% (95% CI 9.9–34.3%). Conclusions Simple interventions aiming to improve staff relationships with patients can reduce the frequency of conflict and containment. Trial registration IRSCTN38001825.

                Author and article information

                BJPsych Open
                BJPsych Open
                BJPsych Open
                Cambridge University Press (Cambridge, UK )
                May 2019
                24 April 2019
                : 5
                : 3
                : e37
                [1]Research Assistant, Division of Psychiatry, University College London , UK
                [2]Research Associate and Honorary Lecturer, Health Service & Population Research Department, Institute of Psychiatry , Psychology and Neuroscience, King's College London, UK
                [3]Research Assistant, Health Service & Population Research Department, Institute of Psychiatry , Psychology and Neuroscience, King's College London, UK
                [4]Professor of Social and Community Psychiatry, Division of Psychiatry, Faculty of Brain Sciences, University College London , and Camden and Islington NHS Foundation Trust, UK
                [5]Professor of Collaborative Mental Health Nursing, Division of Nursing, School of Health Sciences, City University , UK
                [6]Lecturer in Women's Mental Health, Health Service & Population Research Department, Institute of Psychiatry , Psychology and Neuroscience, King's College London, UK
                Author notes
                Correspondence: Syeda Akther, UCL Division of Psychiatry, 6th Floor Maple House, 149 Tottenham Court Road, London W1T 7NF, UK. Email: syeda.akther.16@ 123456ucl.ac.uk
                Author information
                S205647241900019X 00019
                © The Royal College of Psychiatrists 2019

                This is an Open Access article, distributed under the terms of the Creative Commons Attribution-NonCommercial licence ( http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

                : 28 November 2018
                : 18 February 2019
                : 25 February 2019
                Page count
                Figures: 1, References: 92, Pages: 10

                systematic review,meta-synthesis,qualitative,mental health legislation,involuntary admission


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