Should Medicine Face Up to Coercion?

10 Should Medicine Face up to coercion?

showing high levels of aggression on medical wards and in 10 emergency departments (EDs) worldwide.[6] Studies in India[7] 11 and other Asian countries suggest similar problems in medical 12 wards in Asia,[8] indicating that it is not a culture‐bound 13 phenomenon. Surprisingly, few studies have investigated 14 restraint prevalence in medical wards.[9] The dearth of data 15 for medical settings, in contrast to psychiatric settings, shows 16 a remarkable difference in our perception of where coercion 17 happens and where it matters. However, this is in sharp contrast 18 to the data showing that nonpsychiatric settings such as ED, 19 psychogeriatric wards, ambulance services, and others are 20 more at risk from aggression[10] and thus also the increased 21 likelihood of using restraint. This lack of awareness of restraint 22 within medicine happens in an environment of increasing 23 attempts to fight the stigmatization of psychiatry, exemplifying 24 that much more work needs to be done. 25

Medical patients are also treated differently from psychiatric 26 patients by the law, especially when it comes to coercion. As

an example, a person with dementia who lacks capacity in an 27 English medical hospital may be coerced under the Mental 28 Capacity Act (2005) without any need to record and report 29 figures regularly. In contrast, the same patient in a psychiatric 30 hospital would have all their restraint episodes recorded 31 in detail, analyzed, and reported periodically. Similarly in 32 Sweden, a patient detained for a substance misuse problem 33 under the Compulsory Psychiatric Care Act would have all 34 their longer episodes of coercive measures recorded and 35 reported immediately. The same patient could be detained in 36 a medical ward under the Care of Substance Abusers (Special 37 Provisions) Act, and their coercion would neither be defined 38

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11 Under the United Nations Convention on the Rights of Persons 12 with Disabilities (UNCRPD) Article 14, for people with 13 disabilities receiving medical care, the article ensures that their 14 rights are preserved, and they are not deprived of their liberty 15 unlawfully or arbitrarily. In addition, Article 14 requires that 16 people with disabilities receive reasonable accommodation, 17 aiming to move away from coercive measures in treatment. 18 In contrast to psychiatry, there is little discussion about using 19 and reducing restraint in medicine. We suggest that medicine 20 starts this discussion by developing and implementing effective 21 restraint reduction strategies to improve patient and staff safety 22 and reduce traumatization.

24 coercion in Medicine 25

26 The UNCRPD, Article 14 ensures that their rights are preserved and not deprived of their liberty unlawfully or arbitrarily 27 for the person with disability.[1] This includes largely any 28 coercive measures used in medicine, such as chemical, 29 physical, mechanical, or psychological restraint, seclusion, 30 and covert medication. The convention’s demands have caused 31 widespread discussions within psychiatry about the use of 32 restraint, but there has been almost complete silence within 33 other medical specialties. This is surprising, given that coercion 34 is common in medical wards where a large number of elderly 35 patients get treated,[2] and restrained aggressive patients have 36 worse outcomes than those not restrained.[3] A systematic 37 review has shown that the prevalence of incapacity among 38 medical patients is 34%.[4] This is understandable because 39 many medical patients suffer from delirium, dementia, or other 40 illnesses that can affect capacity. While coercion may occur in 41 these contexts, it usually happens within treatment principles 42 and values guiding medical practice. Notwithstanding benign intent when using coercive measures, we know that there is 43 a relationship between aggression on staff and coercion use, 44 and reducing aggression reduces coercion.[5] Data are available

Bevinahalli Nanjegowda Raveesh1, Peter Lepping1,2,3, Tom Palmstierna4,5 6

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5Norwegian University of Science and Technology, Trondheim, Norway

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Address for correspondence: Prof. Peter Lepping, Wrexham Maelor Hospital Psychiatric Liaison Team, Betsi Cadwaladr University Health Board Liaison Psychiatry, Croesnewydd Road, Wrexham LL13 7TD, UK. E‐mail: peter.lepping@wales.nhs.uk

How to cite this article: Raveesh BN, Lepping P, Palmstierna T. Should medicine face up to coercion? J Psychiatry Spectr 2024;XX:XX‐XX.

Submitted: 12‐Jul‐2024; Revised: 17‐Jul‐2024; Accepted: 18‐Jul‐2024; Published: ***.

1 by law nor is there a need to record or report it. In India, any

2 patient restrained under the Mental Healthcare Act (2017) will

3 have their restraint episode reported and monitored, whilst

4 this does not happen to a patient restraint in a medical ward.

5 In the US, detailed data are available for restraint episodes

6 in psychiatry but not in other fields of medicine.[11] These

7 examples show that the same patient can have the same

8 coercive experience. Still, they are perceived and recorded

9 in substantially different ways, depending on whether they

3. Solutions evaluated and implemented in psychiatric 1 settings may be of help to develop measures relevant to 2 medical wards 3

10 are in a medical or a psychiatric ward. We can only speculate what the reasons for this discrepancy might be. Still, it may be

11 rooted in psychiatry’s history[12] and societal and professional

2. 3.

4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Committee on the Rights of Persons with Disabilities. Guidelines on 7 Article 14 of the Convention on the Rights of Persons with Disabilities. 8 The Right to Liberty and Security of Persons with Disabilities. 9 (CRPD/C/12/2, Annex IV); 2015. 10 Frengley JD, Mion LC. Incidence of physical restraints on acute general

12 stigma[13] against mental illness.

medical wards. J Am Geriatr Soc 1986;34:565‐8. 11 Harris CM, Gupta I, Beydoun H, Wright SM. Outcomes for hospitalized 12 aggressive and violent patients when physical restraints are introduced. 13 J Patient Saf 2023;19:216‐9.

14 minimize harm and prioritize patient well‐being, necessitating

Health‐care providers are ethically and legally obliged to 15 a reduction of coercion and restraint. However, we do not

know its precise extent and character because there is no

Lepping P, Stanly T, Turner J. Systematic review on the prevalence of 14 lack of capacity in medical and psychiatric settings. Clin Med (Lond) 15 2015;15:337‐43. 16 Abderhalden C, Needham I, Dassen T, Halfens R, Haug HJ, Fischer JE.

Structured risk assessment and violence in acute psychiatric wards: 17 Randomised controlled trial. Br J Psychiatry 2008;193:44‐50. 18 Hahn S, Zeller A, Needham I, Kok G, Dassen T, Halfens RJ. Patient 19 and visitor violence in general hospitals: A systematic review of the

17 data on coercion in medical wards. This makes it difficult 18

19 to engage staff in measures that would reduce coercion. It

limits our possibilities to reflect upon what is reasonable and

literature. Aggress Violent Behav 2008;13:431‐41. 20 Raveesh BN, Lepping P, Lanka SV, Turner J, Krishna M. Patient and 21 visitor violence towards staff on medical and psychiatric wards in India. 22 Asian J Psychiatr 2015;13:52‐5. 23 Liu J, Gan Y, Jiang H, Li L, Dwyer R, Lu K, et al. Prevalence of

20 proportionate and what is not. By not reflecting on our practice,

21 we may lose the opportunity to discuss when coercion may 22

23 have been unnecessary, and chances to act in alternative ways are missed. This has the potential to harm patients and staff

24 alike. There is good evidence that both staff and patients can get

25 traumatized[14] and retraumatized by coercion. Injuries and even

26 deaths have occurred. Staff can get injured and psychologically

27 traumatized, particularly when coercion is done haphazardly and without prior training. Coercion reduction thus has the

29 potential to improve staff safety, patient safety, and therapeutic

workplace violence against healthcare workers: A systematic review and 24 meta‐analysis. Occup Environ Med 2019;76:927‐37. 25 Azizpour M, Moosazadeh M, Esmaeili R. Use of physical restraints

in intensive care unit: A systematic review study. Acta Med Mediterr 26 2017;33:129‐36. 27 Violence in the NHS | Nuffield Trust; 2022. Available from: https:// http://www.nuffieldtrust.org.uk/resource/violence-in-the-nhs. [Last accessed 28 on 2023 Feb 01]. 29 Gupta I, Nelson‐Greenberg I, Wright SM, Harris CM. Physical restraint 30 usage in hospitals across the United States: 2011‐2019. Mayo Clin Proc

30 relationships. 31

Innov Qual Outcomes 2024;8:37‐44. 31 Lepping P, Poole R. Psychiatry’s need for Vergangenheitsbewältigung: 32 ‘Culture wars’, cognitive dissonance and coming to terms with the past. 33 BJPsych Open 2022;8:e202.

32 concluSion

33 To get to a point where effective reduction management[15] can

34 be implemented on medical wards with all the potential, we

35 ought to look at a stepwise approach:

Fazel S, Ebmeier KP. Specialty choice in UK junior doctors: Is 34 psychiatry the least popular specialty for UK and international medical 35 graduates? BMC Med Educ 2009;9:77. 36 Strout TD. Perspectives on the experience of being physically restrained:

36 1. 37

38 2. 39

The starting point may be acknowledging coercive measures on medical wards as coercion

The next step would be to explore the character of coercion in any given local setting, examining the extent of coercion and which strategies for reduction may be particularly pertinent in that setting

An integrative review of the qualitative literature. Int J Ment Health 37 Nurs 2010;19:416‐27. 38 Steinert T, Baumgardt J, Bechdolf A, Bühling‐Schindowski F, Cole C, 39 Flammer E, et al. Implementation of guidelines on prevention of

Raveesh, et al.: Coercion in medicine

2 Journal of Psychiatry Spectrum ¦ Volume XX ¦ Issue XX ¦ Month 2024

4. Restraint reduction strategies are ratified and implemented. 4 5 reFerenceS 6

coercion and violence (PreVCo) in psychiatry: A multicentre randomised 40 controlled trial. Lancet Reg Health Eur 2023;35:100770. 41