Post-Seclusion and/or Restraint Review in Psychiatry: A Scoping

Review
Article Outline
I.

Method

II.

Results
A.

Study Description

B.

The Theoretical Origins of Post-Seclusion and/or Restraint Review

1.

Psychology and Debriefing

2.

Nursing and Reflective Practice

C.

Post-Seclusion and/or Restraint Intervention Models

1.

Review for the Health Care Providers

2.

Review for Patients

3.

Review for Patients and Health Care Providers

D.

III.

Evaluation of Post-Seclusion Review: The Current State of Knowledge

1.

Frequency

2.

Utility

3.

Efficacy
Discussion

A.

Models and Reflective Practice

B.

Study Limitations

IV.

Conclusion

V.

References

Jump to Section

Abstract
Context

It has been suggested that after an incident in which a patient has been placed in seclusion or in
restraints, an intervention should be conducted after the event to ensure continuity of care and
prevent recurrences. Several terms are used, and various models have been suggested for postseclusion and/or restraint review; however, the intervention has never been precisely defined.
Objective

This article presents a scoping review on post-seclusion and/or restraint review in psychiatry to
examine existing models and the theoretical foundations on which they rely.
Method

A scoping review of academic articles (CINAHL and Medline database) yielded 28 articles.
Results

Post-seclusion and/or restraint review has its origins in the concepts of debriefing in psychology
and reflective practice in nursing. We propose a typology in terms of the intervention target,
including the patient, the health care providers, or both.
Implications

The analysis found that the review ought to involve both the patient and the care providers using
an approach that fosters reflexivity among all those involved in order to change the practice of
seclusion in psychiatric settings.
Accessible summary

Established literature documented widely that seclusion and restraint has

adverse physical and psychological consequences for patient and for health
care providers.

Post-seclusion and/or restraint review is promoted in most guidelines, but there

is no scoping or systematic review yet on the subject.

The origins of post-seclusion and/or restraint review are in the concepts of

debriefing in psychology and reflective practice in nursing.

We propose that post-seclusion and/or restraint review should focus on both

patients and health care providers.

Systematic post-seclusion and/or restraint review should be performed after

each event, and its effects on patients and on mental health professionals
should be rigorously assessed.

In adult psychiatric settings, when other measures fail, aggressive inpatient behavior may result in the treatment team placing the
patient in seclusion and/or restraints (SR). The Ministre de la Sant et des Services sociaux du Qubec (MSSS, 2011, p. 6) defines
seclusion as a A control measure that consists in confining an individual to a location for a specific period of time and from which
the person may not leave freely, and restraint as a A control measure that consists in preventing or limiting a person's freedom of
movement by using human strength, any mechanical means or by depriving the person of an instrument used to offset a handicap.
However, as has been widely documented, SR has adverse physical and psychological consequences for patients. The physical
consequences in particular sparked a major public debate after theHartford Courant published an expos revealing numerous
adverse incidents, including more than 142 deaths linked to the application of control measures (Weiss, Altimari, Blint, & Megan,
1998). Also of concern though are the effects of SR on nurses, both on a personal and professional level (Bonner et al., 2002, Larue
et al., 2010). Nurses who play a key role in the circumstances leading up to and in the aftermath of SR episodes must deal with
emotional discomfort, including feelings of shame, fear, and distress and concern they may be abusing patients' rights when they
initiate an SR procedure.

Mindful of these adverse outcomes, best practices in SR have thus incorporated a post-seclusion and/or restraint review (PSRR).
Several SR reduction programs have been advanced (Ashcraft et al., 2012, Azeem et al., 2011, Huckshorn, 2004, Stewart et al.,
2010). These generally include the following components: organizational leadership, patient education on aggression management,
staff training, changes to the environment, and post-seclusion and/or restraint review. For the programs that have been evaluated,
the findings show a 50% to 75% reduction in the application of SR (Fisher, 2003, Huckshorn, 2004, Lewis et al., 2009, Putkonen et
al., 2013, Wieman et al., 2013). However, the emphasis on comprehensive solutions makes it difficult to determine whether their
efficacy might be due to the program as a whole or to one of its components. Moreover, despite the great interest in the development
of PSRR, it seems to be the most difficult component to implement (Needham & Sands, 2010). Studies on patients' experience of
seclusion (Cano et al., 2011, Kontio et al., 2012) and nurses' perceptions of SR (Bonner and Wellman, 2010, Larue et al.,
2010,Secker et al., 2004) highlight the need to perform reviews of such events. As well, Mayers, Keet, Winkler, and Flisher
(2010)) have found that patients experience greater distress when PSRR is not conducted.

On the whole, according to the research, PSRR is highly recommended and vital to improving the care experience for both patient
and staff, developing best practices, and reducing the incidence of SR (Bonner, 2008, Fisher, 2003, Huckshorn, 2004, Needham and
Sands, 2010, Pollard et al., 2007, Taxis, 2002, Taylor and Lewis, 2012). The practice is widely promoted in SR guidelines, although
its effects have not yet been reported in a systematic review. However, the definition of PSRR and the process vary from study to
study and cannot be properly tested until it has been clearly defined. The aim of this scoping review is to examine existing models
and the theoretical foundations on which they rely.

Jump to Section

Method
A comprehensive scoping review was carried out to answer the following question: what is known on post-seclusion and/or restraint
review in psychiatry? According to a Cochrane review, this method is relevant to explore the extent of the literature in a specific
domain (Armstrong, Hall, Doyle, & Waters, 2011). The following steps are included: 1) identifying the research question and relevant
studies, 2) charting the data, and 3) summarizing the results. A scoping review of English and French articles was carried out using
the search strategy (MH Psychiatric Care) OR (MH Psychiatric Nursing+) OR (MH Mental Health Services+ AND (MH
Debriefing) OR (MH Post seclusion) OR (MH Post incident) OR (MH Post event) OR (MH Aftermath). A date range was not
used since this was an exploratory process. The result was 87 articles from the CINAHL database and 106 articles from Medline (37
were duplicates). Following discussions between the two authors, the inclusion criteria were refined, limiting the review to articles in
English or French, adult psychiatry, and to articles that discussed the concept, its process, or its evaluation. Out of 156 articles, 20
were retained for further analysis. Since there are few empirical studies on PSRR, the review was broadened to include studies on
debriefing by examining references cited in the articles (n=8), for a total of 28 articles ( Fig. 1). The results are presented according
to the analysis of emerging themes.

Fig. 1
Flow diagram of study selection.
View Large Image | View Hi-Res Image | Download PowerPoint Slide

Jump to Section

Results
Jump to Section

Study Description
Studies identified focusing on PSRR are mostly qualitative and descriptive, with only one proposing an experimental design. They
are conducted in acute psychiatric inpatient units, mainly in Australia, the UK, the US, and Canada. PSRR is discussed based on
patient and staff experiences, as an intervention per se(Table 1) or as a component of a program (Table 2).

Table 1Studies

Authors

Reporting Post-Seclusion and/or Restraint Review.

Aim of the
study
To establish the
feasibility of using
semistructured
interviews with
patients and staff in
the aftermath of
untoward incidents
involving physical
restraint and to
gather information on
the factors patients
and staff groups found
helpful and unhelpful.

Method

Intervention

Main results

Descriptive

Postincident
debriefing

- PSRR valued by all but

not systematic.

Semistructured interviews
with patients (n=6) and staff
(n=12)

- Patients: kindness in the

staff is perceived helpful,
but they feel ignored and
unheard particularly in
the aftermath.
-Staff: the aim is for
reviewing the events and
evaluating decisions and
actions taken. Can be
formal or informal.

Bonner et
al. (2002))

- Need to establish
policies and mechanisms
for after incident
debriefing to all staff and
patients involved.

UK
Secker et
al. (2004))
UK

To take a more
systemic approach by
treating violent and
aggressive incidents
as social interactions
and by seeking to
understand the social
contexts in which they
took place.

Descriptive (n=15 staff)

Discussion

- Little attempt to reflect

on and learn from the
incidents, either with the
clients involved, or as a
staff team.
- Discussion in the
aftermath in 7 of the 11
cases.
- The aim is to correct the
client's behavior, rather
than exploring what had
happened from the
client's perspective or
considering how it might
have been avoided.
- 3 steps required
following an aggressive
incident: emotional

support; critical reflection

and learning; pursuit of
accountability.

Prescott,
Madden,
Dennis,
Tisher, and
Wingate
(2007))

To describe the use of

rapid response teams
to reduce the use of
mechanical restraints

Action research

Restraint rapid
response team
meetings

- On a 6-week rapid cycle

change process, reduction
of mechanical restraints
by 36.4%.
- Opportunities for realtime supervision and
experiential learning.

USA
Allen, de
Nesnera,
and
Souther
(2009))

To describe a standard
meeting time and
place for an
executive-level review
of every episode of
seclusion and
restraint

Descriptive

Exploratory, action research

Australia

To describe current
clinical practice and
explore debriefing
needs as expressed
by consumer
consultants and
mental health nurses
in order to consider
the desirability of
developing a training
program to facilitate
post-seclusion
debriefing.

Survey design with

Bonner and
Wellman
(2010))

To evaluate whether
staff and inpatients
had found
postincident review
helpful after incidents
involving restraint.

To investigate the
frequency and type of
post-seclusion
debriefing provided by
nurses

Exploratory

Executive-level review
(witnessing)

Demonstrates the
organization's
commitment, provide
data about factors,
promotes creative
thinking, collaborative
problem solving and the
exploration of new ideas
recommended by those
directly involved.

Post-seclusion
debriefing

Consumer consultants
need more emotional
support from debriefing to
deal with negative
feelings.

Data collected for 3years

USA

Ryan and
Happell
(2009))

Focus group with mental

health nurses (n=31) and
consumer consultants (n=4)

- A range of informal and

unstructured approaches
is used for debriefing, but
note always meet
consumer consultant
preferences (who, when
and what).

Postincident review

Staff (n=30) and inpatients

(n=30)

- 87% of staff and 60% of

patient agreed the review
had allowed them to think
about how the incident
had been managed.

Australia
Needham
and Sands
(2010))
Australia

- 97% of staff and 94% of

patient agreed the review
was useful.

Retrospective file audit on

case files (n=63)
Criteria within 3days:
support and reassurance,
counseling, ventilation,
physical support and
psychoeducation.

Post-seclusion
debriefing

- 58.8% had PSRR

(presence of one of the
five criteria)
- More female consumers
(70%) than males (53.5%)
- Only 23,5% of males
have more than one
criteria

- Most frequent criteria:

support/reassurance and
counseling
- An explicit mention of
post-seclusion debriefing
in 1/63 cases.

To explore and
describe nursing
interventions
performed during
episodes of seclusion
with or without
restraint in a
psychiatric facility and
examine the
relationship between
the interventions'
local protocols and
best-practice
guidelines.

Descriptive

2 activities:

Semistructured interviews
with nurses (n=24)

Post-event review with

the patient
Post-event review with
healthcare team

- 3 main elements:
reflective practice
focusing on the steps of
the decision-making
process; a discussion of
emotions; and projections
for future interventions in
similar circumstances

Canada
To understand the
perception of patients
regarding application
of the seclusion
and/or restraint
protocol.

Exploratory descriptive study

2 activities:

A survey using a Likert scale

in individual face-to-face with
6 questions regarding PSRR

Post-event review with

the patient

n=50 patients

Post-event review with

healthcare team

Larue et al.
(2013))
Canada

Australia

- Aim is an explication,
not seeking client's
experience or trying to
find alternative measures
- Reviews with the team
only if problems have
been encountered to
adjust the interventions
and no discussion on
emotions.

Larue et al.
(2010))

Whitecross,
Seeary,
and Lee
(2013))

- Only 9/24 reported to

review incident with the
patients.

To identify the impacts

seclusion has on an
individual and
measure the
effectiveness of a
post-seclusion
counseling
intervention in
mitigating the
experience of
seclusion-related
trauma and reducing
time spent in

- Before and after with a

comparison group
- Self-reported experience of
trauma symptoms using the
Impact of Events Revised
Intervention group (n=17)
Comparison group (n=14)

Single-session postseclusion counseling:

counseling,
ventilation, support
and reassurance,
screening physical
adverse effects,
psychoeducation,
factors, how to avoid

- Nearly all patients

perceived that the health
care team did not followup with them after
seclusion
- Patients agreed only
somewhat with
statements about postseclusion follow-up (1.61,
SD=1.08), follow-up
regarding feelings (1.56,
SD=0.97) and discussion
to understand what had
happened (1.6, SD=
0.87)

- Trauma symptoms: not

significant
- Number of seclusion
episodes: not significant
(t(15.6)=0,95, P=0.36)
- Time in seclusion:
significantly fewer (t(29)
=2.70, P=0.01)

seclusion.

Table 2Studies

Reporting Post-Seclusion and/or Restraint Review as a Part of a

Program.

Authors

Fisher
(2003))

Aim of the study

Method

To describe elements of a
successful restraint reduction
program and their application.

Descriptive
Seclusion rate
(expressed in
physicians orders
per 1000 recipients
days)

USA

Huckshorn
(2004))

To present core strategies for

reduction of seclusion and
restraint use in mental health
settings based on a prevention
approach.

Not described

PSRR of the
program

Main results

2 types of post-event
discussions.

- Reduced SR rate by 67%

over a period of 2years.

- Post-event analysis

- Both staff and recipients

(>90%) endorsed the
value of post-restraint
debriefings in preventing
repeat occurrences.

- Debriefing with the

recipient and his
regular treatment
team

Debriefing
procedures:
- immediate postincident review
- formal analysis of
the incident

USA

- patient debriefing

To describe the implementation

and the evaluation of a no force
first policy, an active program to
avoid and eliminate the use of
force, including seclusion,
mechanical restraint, and
pharmacological restraint and
forced medication.

Descriptive, pre
and post

Debriefing with the

consumer

Over a 58-month
follow-up

Critical incident
review

Number of
seclusion and
restraint episodes

- Staff learned to listen

closely to people and to
give them what they were
asking for whenever
possible.
- Informed new crisis
intervention and
deescalation training
manual.

USA

Finland

- Larger crisis center took

10months until a month
registered 0 seclusions
and 31months until 0
restraints.
- Smaller crisis center took
2months and 15months.

Ashcraft et
al. (2012))

Putkonen
et al.
(2013))

6 core strategies: 1)
leadership, 2) use of data,
3) workforce
development, 4)
assessment and
prevention tools, 5)
involvement of
consumers/family
members, 6) eventdebriefing procedures.

To study the feasibility of

preventing coercive measures
without violence for males with
schizophrenia in applying six core
strategies.

Cluster-randomized
controlled trial
2 intervention
wards

Postevent analysis

- PatientDays with SR or
room observation:
declined from 30% to 15%
for intervention wards vs
25% to 19% for control
wards.

2 control wards
- SR time decreased from
110 to 56h per 100 bed
patientdays vs an
increase of 133 to 150h

for control wards

To describe an evidenced-based
performance improvement
program that resulted in a
decrease in the use of SR.

Lewis et al.
(2009))

Descriptive
pre/post
Hours of seclusion
Hours of restraint

Witnessing program:
immediate post
event debriefing
formal and rigorous
interview

- No increase in patient or
staff injuries.

To present the initiatives that

were introduced during a
seclusion reduction project based
on the six core strategies that
were undertaken.

- Post-seclusion
debriefing

Number of
seclusion events
and patients
secluded

- Seclusion review
process

To review and evaluate a variety

of interventions that were
considered to have contributed
to the successful reduction of
reliance on the use of SR in a
public psychiatric hospital for
adult patients with severe and
persistent psychiatric
impairments.

Multiple regression
analysis to monthly
SR on 5years.

To report changes in patterns of

seclusion use and adverse
incidents over a 5-year period
(information and transparency,
audit and peer reviews, risk
management, patient
involvement, training and
leadership)

Descriptive
pre/post

To examine implementation and

outcomes of the Six Core
Strategies for Reduction of
Seclusion and Restraint.

Descriptive
pre/post

USA
Qurashi,
Johnson,
Shaw, and
Johnson
(2010))

Descriptive
pre/post

- A reduction of seclusion
events and the hours of
seclusion.
- A lesser reduction in the
number of patients that
was secluded.

Hours of
seclusion/month

Australia

Donat
(2003))

- Decrease of restraint
ranging from 2097%.
- Decrease of seclusion of
3063%.

USA
Maguire,
Young, and
Martin
(2012))

- 75% reduction in the use

of SR.

Case review
committee

Program's
component: criteria
for review, case
review committee,
behavioral
consultation team,
standards for
behavioral
assessments, staff
patient ratio

- Reduction of 75% in the

use of seclusion and
restraint
- The only variable that
was significantly
associated with reduction
in the use of SR was
changes in the process for
identifying critical cases
and initiating a clinical
and administrative case
review.

Seclusion peer group

review meeting

Number of
seclusion episodes

- A reduction of 67% of the

number of seclusion
episodes per month
- A decrease of the
incidents recorded

Number of
incidents recorded

UK
Wieman et
al. (2013))
USA

n=43 psychiatric
facilities

Debriefing

- Reduction of the %
secluded by 17% (p
=.002)
- Reduction of the
seclusion hours by 19% (p
=.001)
- Reduction of the
proportion restrained by
30% (p=.03).

- No significant reduction
reduction in restraint
hours
- Individual facility effect
sizes varied;

McCue,
Urcuyo,
Lilu,
Tobias, and
Chambers
(2004))

To describe a program to reduce

the use of restraint (better
identification of patients,
stress/anger management group,
staff training on crisis
intervention, crisis response
team, daily review of restraints,
incentive system for staff).

Prospective study
pre/post

Daily review of all

restraints.

Unpaired ttailed ttest

Rate of restraint
use: number of
restraints/1000
patientdays

- Significant decrease in
the rate of restraint use:
(mean SD: before=7.99,
after=3.70; p<.0001)
- No sustained increase in
incidents of assault,
suicidal behavior, or selfinjury.

USA
Jump to Section

The Theoretical Origins of Post-Seclusion and/or Restraint Review

Jump to Section

Psychology and Debriefing

Post-seclusion and/or restraint review, which we initially define as an intervention performed after a psychiatric patient has been
placed in seclusion, traces its origins to the concept of debriefing in psychology. Psychological debriefing is generally defined as an
early intervention method for personnel groups exposed to a single task or repetitive tasks related to stressful events that carry a
high potential for psychotraumatic effects (Raphael & Wooding, 2004, p. 44). The most commonly used debriefing intervention
model, Critical Incident Stress Debriefing, seeks to encourage individuals to express their emotions following a traumatic incident in
order to reduce adverse psychological consequences (Mitchell, 1983). However, a Cochrane meta-analysis performed in 2002 and
revised in 2009 challenged the validity of findings showing a positive impact of debriefing on persons exposed to a traumatic event
(Rose, Bisson, Churchill, & Wessely, 2009). A review of 15 randomized controlled studies concluded that the practice did not reduce
psychological distress or prevent post-traumatic stress; debriefing was found to have a null effect as compared to the care given a
control group and, in some cases, to potentially increase risk. Consequently, although the Cochrane meta-analysis has been
criticized in turn (Tuckey, 2007), there is palpable discomfort over the use of this concept. Debriefing has nevertheless entered the
realm of popular psychology, and its use has extended to the field of mental health.

Jump to Section

Nursing and Reflective Practice

Since disciplines interact and influence each other constantly, concepts of each other's travel too. In this regard, nurses have
integrated the concept of emotional communication for health care providers. They have found that in addition to lowering their
stress levels, debriefing also fosters reflective practice (Bell, 1995). It is suggested that the expression of emotions leads nurses to a
critical analysis of clinical practices, an exploration of the appropriateness of the therapeutic skills used, and the promotion of safe

practices (Morante, 2005). By applying the concept of debriefing to their discipline and mental health, nurses have thus added the
dimension of reflective practice to the original emotional dimension of debriefing. They use the concept of debriefing in the broader
sense of an emotional exchange that leads the health care providers to engage in reflective practice. As has been amply
documented, incident reviews of this sort have become a vital tool of reflective practice in nursing through such strategies as
debriefing and review with peers (Goulet, Larue, & Alderson, 2015). In this regard, it is a means of obtaining feedback in the context
of an educational activity or a clinical experience to help nurses integrate previously acquired knowledge. Significant-event reviews
foster learning that becomes meaningful when one engages in deep introspection through reflection (Dreifuerst, 2009), allowing for
the verbalization and integration of experiential knowledge. As currently used, therefore, in contrast to debriefing, reflective practice
is concerned less with the expression of feelings than with communication that nurtures each team member's potential. Although
initially presented as a debriefing activity, we believe that PSRR can only achieve its full transformative potential if it is presented as
a form of reflective practice within the context of control measures (Fig. 2).

Fig. 2
The theoretical origins of post-seclusion and/or restraint review.
View Large Image | View Hi-Res Image | Download PowerPoint Slide
Awareness of the two principal sources of PSRR contributes to a better understanding of how the concept emerged and how it can
support skill development in nursing staff in order to reduce SR. However, reference to the notion of debriefing in psychiatry and
psychology immediately conjures up the harsh criticism leveled in this regard in the Cochrane analysis (Rose et al., 2009). This
vociferous debate in the scientific community and the accretion of new dimensions are likely the reason so many and such
conceptually vague terms are used to refer to the various forms of intervention conducted after the seclusion of psychiatric
inpatients. The following is a non-exhaustive list of the terminology: post-event discussion (Fisher, 2003), post-seclusion debriefing
(Needham and Sands, 2010, Ryan and Happell, 2009), debriefing procedures (Huckshorn, 2004, Lewis et al., 2009, Maguire et al.,
2012), post-incident review (Bonner & Wellman, 2010), post-event analysis (Putkonen et al., 2013), witnessing (Allen et al.,
2009, Taylor and Lewis, 2012), post-seclusion counseling intervention (Whitecross et al., 2013) and post-event review (Larue et al.,
2013). We propose the term post-seclusion and/or restraint review not only to move away from the concept of debriefing as already
described by Bonner (2008)) but also to specify the incident involved: seclusion and/or restraint. We will now examine the various
intervention models.

Jump to Section

Post-Seclusion and/or Restraint Intervention Models

The authors in our literature review describe a number of post-seclusion and restraint interventions but offer no explicit typology. To
compensate for this shortcoming, we suggest a PSRR typology based on the target of the intervention: the health care providers
(especially nurses), the patient, or both.

Jump to Section

Review for the Health Care Providers

Some of the suggested forms of PSRR were developed specifically for health care providers. In Canada, the Omega training
program has enjoyed great popularity; it has been widely implemented in many French-language hospitals and is taught in several
undergraduate nursing programs (Boyer, Guay, & Goncalves, 2014). It centers on patient pacification and developing skills and
modes of intervention to ensure the safety of the health care professional and others in aggressive situations (ASSTSAS, 2006, p. 9
[Translation]). The Omega program sets out a two-stage intervention for reviewing disruptive events. First is immediate feedback,
consisting of the administration of first aid and discussion, analysis, and documentation of the incident by the treatment team. This is
followed by a post-incident reviewthat includes one-on-one or group debriefing sessions with a support person to explore their
understanding of the intervention, plan future interventions, and meet with the patient if necessary. This part of the program has
never been evaluated empirically. Such analysis is similar to the psychiatric rapid response team described byPrescott et al. (2007)),
which primarily aims to develop a hypothesis on the cause of SR to make appropriate changes in the treatment plan. A PSRR on a
more executive level is also suggested (Allen et al., 2009). It takes the form of a daily meeting with the medical director and
immediate staff and provides a narrative description of the incident as well as an opportunity to share perceptions and emotions.

Although patients are mentioned in this type of program, the intervention is rooted in a philosophy that is more organizational than
clinical in nature. It focuses less on patient-centered humanistic care than on staff safety, although it could be directed at both.
Moreover, the Omega program suggests meeting with patients if necessary and, if appropriate, having them take responsibility for
their behavior (e.g. asking for an apology or taking legal action).

In a Finnish exploratory study on training requirements for aggression management, nurses (n=22) and physicians (n= 5) indicated
in focus group that in addition to a need for peer support in order to engage in a learning experience through post-seclusion
debriefing, they also required professional support after an especially trying SR incident (Kontio et al., 2009). The study thus
implicitly brings to light the reflective dimension of PSRR. Although the need for staff to take part in an organized review is
expressed, no definition or model is provided for the review. Indeed, in an action research developing a rapid response team to
reduce the use of SR (Prescott et al., 2007), meetings after each incident are an opportunity for real-time supervision and
experiential learning.

The primary feature of these types of PSRR for health care providers is a concern for the safety of both the staff and the patient; yet
the latter does not figure extensively in the process. One might think, from the literature, that PSRR would offer an excellent

opportunity for reflexivity; however, only few studies (Kontio et al., 2009,Prescott et al., 2007) raised the possibility of using the
review as a form of staff learning within Schn's (1983))meaning of reflection on action.

Jump to Section

Review for Patients

Some of the interventions in the literature are aimed exclusively at patients. However, these studies are still in the early
stages. Bonner and Wellman (2010)) and Needham and Sands (2010)) maintain that the models developed in the field of
psychology cannot be applied to patients in the context of SR. Needham and Sands (2010, p. 230)) therefore recommend
developing a post-seclusion debriefing model that clearly lays out the conditions of the intervention: This model needs to include the
most appropriate timing to provide debriefing, who should provide the intervention, the consumers' response to debriefing, and
guidelines and framework for communication and consistency. Bonner (2008)), however, does present a framework for a patient
review; the Thames Valley University Post-Incident Review Framework is aimed at helping patients manage their feelings and
explore the reasons for their negative emotions. The model comprises 14 questions to guide the nurse in carrying out a patient
review on the triggering events, factors the patient deems important, and issues to be considered in future situations in which there
is a risk of violence. For their part, Whitecross et al. (2013, p. 513)) define post-seclusion debriefing as an intervention that
potentially supports patients' natural recovery mechanisms after a seclusion event. It can be described as a talking therapy that
offers the patient the opportunity to make sense of their experience and bring about emotional resolution and healing. The content
of the intervention was developed based on the five PSRR-related interventions (counseling, venting, support and reassurance,
screening for physical adverse effects, and psychoeducation) identified by Needham and Sands (2010)). Through this discussion,
the treatment team and the patient identify triggers and signs of escalating aggression as well as the type of preventive intervention
preferred by the patient (Whitecross et al., 2013).

In a review with patients, the objective is thus to help them manage their feelings and find out what caused them to lose control of
their emotions and behave as they did. This objective is consistent with the concept of psychological debriefing in the literature.

Jump to Section

Review for Patients and Health Care Providers

A PSRR that involves activities directed at both the patient and the care providers also exists. Fisher (2003)) was the first to put
forward a two-stage intervention: an immediate analysis with staff to quickly reconstruct the incident between the parties involved
and to draw up a short-term plan, and a debriefing 24 to 48hours later to undertake a detailed analysis that draws on the
perspectives of both the patient and the treatment team in order to plan the next steps and avoid a repetition of seclusion.

In 2004, as head of the National Coordinating Center for Seclusion and Restraint Reduction in the United States, Huckshorn drew
on Fisher's work to develop a model for preventing violence and the utilization of SR:Six Core Strategies for Reducing Seclusion and
Restraint Use. The proposed strategies involve: (a) organizational leadership, (b) analysis of SR data, (c) staff training and
education, (d) prevention tools, (e) patient involvement, and (f) debriefing tools. The SR reduction program is founded on the
deconstruction of myths and assumptions, trauma-informed care, recovery and the public health prevention model. Debriefing

activities are integrated into tertiary prevention with the aim of diminishing the adverse effects of SR on patient and staff and
preventing recurrences. Huckshorn, 2004, Huckshorn, 2005) operationalized the activities outlined by Fisher (2003)) and
underscored the importance of the patient's perspective in the practice review. More specifically, Huckshorn (2005)) outlined three
debriefing activities: First, an immediate post-incident review is carried out with the care providers involved to restore the
environment to a pre-crisis level and physical and emotional security and to document the episode. Then, a formal analysis of the
incident is conducted 24 to 48hours after the seclusion episode by a senior manager who was not involved in the incident. The
treatment teamwith the patient when possibleis asked to analyze the incident following an 11-step, 67-question protocol
(Huckshorn, 2005). The goal is to produce an individualized treatment plan and recommendations. Lastly, patient debriefing by a
person not involved in the event should be conducted as soon as the patient's condition permits to minimize the adverse effects of
SR, share responsibility for the incident, and restore the relationship of trust between patient and staff. Reviews that involve both the
patient and the care providers therefore have multiple components that target both of them. The authors do not discuss PSRR in
terms of team reflexivity; however, it seems to us that the formal review offers the team an excellent opportunity to grow from the
experience by questioning its practices. Indeed, in a study examining violent and aggressive incidents as social interactions, Secker
et al. (2004)) revealed that these incidents were rarely seen as an opportunity to reflect and learn, either with the patient or as a
team.

Thus, some types of seclusion reviews are patient centered, others focus on the health care providers, while others consider both.
Given that SR has been found to adversely affect both patients and staff, it seems appropriate that an intervention should take both
into account. This type of complex intervention would not only respond to the needs of the individuals involved but also improve SR
practices, particularly by fostering team reflexivity. For example, to facilitate the reflective practice of a team, Maguire et al.
(2012)) suggested that a senior nurse should take leadership of the seclusion review process and make recommendations for
practice. According to Secker et al. (2004)) and Larue et al. (2010)), critical reflection and learning should be a core component of
PSRR.

Jump to Section

Evaluation of Post-Seclusion Review: The Current State of Knowledge

Evaluation studies involving seclusion and restraint have usually dealt with SR reduction programs, which include PSRR. Since
PSRR is fully integrated into these programs, it is hard to determine its specific impact on SR reduction. The following is an overview
of studies that have evaluated PSRR in clinical settings and considered its utility and efficacy.

Jump to Section

Frequency
Although most SR protocols contain a PSRR component, the literature offers little information on its practice in clinical settings
(MSSS, 2011). In a 2010 Australian retrospective study, Needham et al. examined case-file notes to document five nursing
interventions (consultation, ventilation, support and reassurance, physical interventions, and psychoeducation) for measuring postseclusion debriefing. The interventions were identified through the literature, but it is difficult to pinpoint the process that led to their

selection or their specific link to PSRR. The authors found that 58.8% of the case files in 63 seclusion events mentioned at least one
of the interventions, but only one file contained a note dealing explicitly with the patient's experience of seclusion. These findings
corroborate those of other studies that showed, in fact, that many patients believed that no SR review was conducted in their
presence (Bonner et al., 2002, Larue et al., 2013, Ryan and Happell, 2009). Moreover, according to staff, PSRR is not discussed as
a systematic intervention. In a Canadian study on nursing interventions pre-, per-, and post-SR, only 9 nurses out of 24 reported
reviewing the incident with the patients (Larue et al., 2010).

Jump to Section

Utility
Although PSRR is not systematically conducted in clinical settings, an exploratory study of the utility of post-incident review
assessed how it is perceived in an acute psychiatric unit in England (Bonner & Wellman, 2010). It was deemed helpful by 97% of
staff (n=30) and 94% of patients (n=30). The utility of PSRR is also highlighted in an exploratory study of six psychiatric units in
two Finnish hospitals (Kontio et al., 2009). Nurses and psychiatrists identified a need for training in post-SR that would take the form
of debriefing of the situations afterward within a peer group as a learning experience (Kontio et al., 2009, p. 203). The participants
thus envisioned training occurring through PSRR.

Jump to Section

Efficacy
The review of the literature revealed only one quantitative study that dealt exclusively with an evaluation of a post-seclusion
intervention. Using an experimental study design,Whitecross et al. (2013)) compared 31 patients who had been placed in seclusion
in an acute psychiatric unit and subsequently received an intervention of post-seclusion counseling with a control group that
received the usual care (review at the patient's request or if the health care provider determined the need). Over 9months, more
than 47% of the sample reported PTSD-like symptoms; there was no significant difference between the groups. However, the
members of the experimental group were subjected to significantly fewer hours of seclusion than the control group (t (29) = 2.70, p=
0.01). According to Whitecross et al. (2013)), a single debriefing session is probably not enough to reduce symptoms of PTSD.
However, given the reduction in SR, they suggest that the implementation of an SR intervention may have made the treatment team
more aware of the issues involved to the point that they changed their practices.

The SR reduction program based on the Six Core Strategies clinical model, which includes a PSRR component, has been the
subject of several evaluations, and the results seem promising. The program has been implemented at 43 American sites, and preand post-introduction information is available for eight states. The data reveal mean reductions of 17% in the number of patients in
seclusion (p=.002), 19% in hours of seclusion (p=.001), and 30% in patients placed in restraints (p=.03) ( Wieman et al., 2013).
The program has also been introduced in Ontario; preliminary data comparing results to those for a control group are encouraging
(Anderson & Waldman, 2012). The introduction of the program in a psychiatric hospital in New York State has led to a 75% reduction
in the use of SR in 4years with no increase in injuries to patients or staff (Lewis et al., 2009, Taylor and Lewis, 2012). Moreover, in a
cluster-randomized controlled study that implemented this model with men with schizophrenia, the proportion of patientdays with

SR or room observation declined from 30% to 15% for intervention wards, and SR time decreased from 110 to 56hour per 100 bed
patientdays (Putkonen et al., 2013).

An SR reduction program of this type has also been implemented in Australia in a forensic hospital, where managing aggressive
behavior is especially challenging given the prison culture and the fact that it houses a population at high risk of aggression (Maguire
et al., 2012). A few individual PSRR initiatives have been introduced in this setting, but the authors stress the value of strengthening
the program so that it can be an opportunity for learning and discussion about the treatment being appliedin other words, a
reflective practice. Over 2years, there has been a reduction in the frequency (occurrences per patient) and duration of seclusion
events but little change in the number of patients in SR as a proportion of inpatients (Maguire et al., 2012).

To sum up, although to date only one study has been conducted that specifically addresses the efficacy of PSRR, programs with a
PSRR component show a 50% to 75% reduction in SR events (Fisher, 2003,Huckshorn, 2004, Lewis et al., 2009, Putkonen et al.,
2013, Wieman et al., 2013). This leads to the question of what the relative weight of the various components, including PSRR, might
be. So far, only the study ofWhitecross et al. (2013)) has attempted to answer this question.

Jump to Section

Discussion
An examination of the origins, theoretical foundations, models, and evaluation of PSRR has helped clarify the intervention.

Jump to Section

Models and Reflective Practice

The scoping review revealed that there are numerous forms of PSRR. We have proposed a typology based on the target of the
intervention, that is, whether it is focused on the patient, the treatment team, or both. By way of clinical vignettes, Boumans, Egger,
Souren, MannPoll, and Hutschemaekers (2012)) established that team reflexivity is inversely related to its tendency to seclude.
Knowing that the use of SR is less determined by the individual characteristics of patients and staff than by the team's characteristics
(Boumans et al., 2012), it is relevant to propose an intervention that initiates collective reflecting. These findings are consistent with
those ofHuckshorn's (2014)) study of leaders and staff who were involved in projects that were successful in reducing the use of SR.
Although, initially, the use of SR was the organizational standard and was not questioned in the settings studied, SR reduction
projects have changed team perspectives toward a much more flexible practice.Huckshorn (2014)) discusses this change in
connection with the concept of team learning in Senge's (2006))organizational change model, which stresses the importance for
treatment teams to be able to change their beliefs and behaviors and hence move toward a new shared vision. According to Lewis et
al. (2009)), developing different PSRR activities in a non-punitive environment, where everyone is encouraged to express
themselves freely, becomes a learning opportunity for all.

If the interaction between patients and their care providers is considered central to the decision of whether to resort to SR, and if the
goal is to produce meaningful learning for patients and improve staff ability to manage aggressive behavior, the most appropriate

course is to select an intervention model that can impact all the levels involved. Although, to our knowledge, PSRR has rarely been
presented as a therapeutic intervention, we believe it could help patients develop their capacity for mentalization, an ability which is
often diminished in mental health populations. Such an intervention would thus also offer patients an opportunity for reflection and
give them a greater sense of empowerment in situations involving aggressive escalation.

Post-seclusion and/or restraint review involves reflexivity on the part of the patient, the treatment team, and the organization. This
reflexivity should ideally contribute to changing the culture of the unit and lead to the adoption of a more comprehensive, holistic
perspective and preventive interventions that promote patient recovery. As a form of reflective practice that embraces both the
treatment team and the patient, PSRR seeks to encourage emotional communication, analysis of the steps that led to the decision to
resort to SR, and planning of future interventions (Fisher, 2003, Huckshorn, 2004). Post-seclusion and/or restraint review is therefore
a method of stimulating critical reflection about seclusion, which is essential to enhancing SR prevention and improving SR
interventions when they are applied. The retrospective facet is crucial: analyzing the clinical decision after the event enables staff to
approach future situations without falling into emergency mode or submitting to automatic reflexes or strict protocols, thereby
improving decision making (Le Coz, 2007). With this in mind, we propose the following definition of PSRR: a complex intervention
taking place after an SR episode targeting the patient and the health care providers in order to enhance the care experience and
result in meaningful learning for the patient, team, and organization.

Jump to Section

Study Limitations
The study's limitations revolve mostly around the methodology. First, because of the multitude of expressions used in discussions on
the concept of PSRR, it is therefore possible that some relevant papers were overlooked despite the fact that many keywords were
used. This also explains why the concept of review was not used in the initial search; it was only added after some of the texts
were read. Second, the analysis would have been more rigorous had each author conducted his or her own literature review and
then obtained inter-rater agreement.

Jump to Section

Conclusion
The proposed typology of PSRR clarifies the concept in terms of the intervention target: the patient, the care providers, or both.
When the issue of SR is approached in a holistic fashion, when the interaction between clinician and patient is placed at the centre
of therapeutic care, it is evident that any proposed solutions must involve both patients and care providers, especially nurses. Thus
clarified and rooted firmly in a nursing and reflective practice perspective, an intervention of this type is sure to reduce the risk of
aggression and the need to resort to control measures. In addition to improving the patient and nurse experience when SR is
involved, PSRR will also help to continually enhance the quality and safety of patient care when managing aggressive behavior. The
review of the literature reveals a paucity of PSRR evaluation studies; this topic merits further research.

Jump to Section

Acknowledgment
The first author received doctoral grants from Quebec Nursing Intervention Research Network, Fonds de recherche du Qubec en
Sant and Canadian Institutes of Health Research.

Suicidal Ideation on Higher Education Students: Influence of Some

Psychosocial Variables
Introduction
While attending to higher education, multiple changes occur in the lives of young students. These
changes make higher education students particularly more exposed and vulnerable to mental health
problems, and therefore more likely to present suicidal behaviors.
Objectives
The aim of this study was to assess suicidal ideation in higher education students, and its
relationship with some psychosocial variables.
Methods
Exploratory, quantitative and descriptive study, applied on a sample of 1074 students of a higher
education institution in Portugal.
Results
Some significant associations with suicidal ideation were found with self-concept factors (selfacceptance, self-effectiveness and impulsivity); stress, anxiety and clinical depression; linkage
anxiety and social support activities dimensions; intimacy and total social support.
Conclusion
In our sample we found 84 students with potential suicidal risk, and through the result analysis, the
biopsychosocial profile of the student at risk for suicidal ideation exhibits the following traits: female,

age 18/19, low self-concept, insecure linkage patterns and little involvement in social activities and
intimacy relationships.
All facts considered, higher education institutions should provide programs that promote mental
health and suicide prevention in academic environments.
The results of this study also have implications for policy makers, clinical practice, suicide prevention
and higher education institutions.

Effects of the nursing psychoeducation program on the acceptance of medication

and condition-specific knowledge of patients with schizophrenia Mitsunobu Matsuda,
Ayumi Kohno PII: S0883-9417(16)30005-X DOI: doi: 10.1016/j.apnu.2016.03.008
Reference: YAPNU 50838 To appear in: Archives of Psychiatric Nursing Received
date: 14 January 2016 Revised date: 22 March 2016 Accepted date: 27 March 2016
Please cite this article as: Matsuda, M. & Kohno, A., Effects of the nursing
psychoeducation program on the acceptance of medication and condition-specific
knowledge of patients with schizophrenia, Archives of Psychiatric Nursing (2016),
doi: 10.1016/j.apnu.2016.03.008 This is a PDF file of an unedited manuscript that
has been accepted for publication. As a service to our customers we are providing
this early version of the manuscript. The manuscript will undergo copyediting,
typesetting, and review of the resulting proof before it is published in its final form.
Please note that during the production process errors may be discovered which
could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT ACCEPTED MANUSCRIPT Title: Effects of the nursing
psychoeducation program on the acceptance of medication and condition-specific
knowledge of patients with schizophrenia Authors: Mitsunobu Matsudaa, , Ayumi
Kohno b a Psychiatric and Mental Health Nursing, Graduate School of Nursing,
Osaka City University, Osaka, 1-5-17 Asahi-machi, Abeno-ku, Osaka, 545-0051 Japan
E-mail address: matsuda.mitsunobu@nurs.osaka-cu.ac.jp b Psychiatric and Mental
Health Nursing, School of Nursing, Senri Kinran University, Osaka, 5-25-1
fujishirodai, suita-shi, Oosaka, 565-0873 Japan E-mail address: akono@cs.kinran.ac.jp Corresponding Author: Mitsunobu Matsuda, Professor, RN, PhD
Phone/Fax : +81-6-6645-3534 E-mail address: matsuda.mitsunobu@nurs.osakacu.ac.jp Key words: Intervention Studies, Acceptance of Medication, Program
Evaluation, Psychiatric Nursing, Psychotherapy, Schizophrenia Authors
contributions: Matsuda assisted statistical analysis, and contributed to the creation
of a draft; and Kohno developed the idea and design of this study, performed
statistical analysis, and provided suggestions on this manuscript. The formers and
latters degrees of contribution to the study were 60 and 40%, respectively. Both
confirmed the final manuscript before approval. Acknowledgements: This research
was funded by Grants-in-Aid for Scientific Research (C) from the Ministry of
Education Culture, Sports, Science and Technology of Japan (no. 25463600; PI:
Ayumi Kohno). ACCEPTED MANUSCRIPT ACCEPTED MANUSCRIPT Many patients with
schizophrenia require long courses of drug treatment to improve their psychological
symptoms and prevent relapses. However, patients who live in local communities
after being discharged are often repeatedly hospitalized due to relapses caused by
poor medication adherence, poor family support, poor interpersonal relationships,
and stressful life events (Xiao et al., 2015). In a study conducted by Schennach et
al. (2012), it was found that 52% of patients with schizophrenia suffered at least one
relapse within a year of their discharge from hospital. In another study, it was
demonstrated that medication discontinuation was the cause of readmission (based
on self-judgment) in more than 70% of patients who were readmitted within a year

of being discharged from hospital (Kissling, 1991). Furthermore, the following

factors were demonstrated to be significant predictors of rehospitalization and
relapse after hospital discharge: a higher Hamilton Depression Rating Scale (HAMD17) score, an increased frequency of side effects, a negative attitude to treatment,
and not having a job (Schennach et al., 2012). Regarding the factors affecting
medication discontinuation, it is considered that medication discontinuation is
influenced by the patient-healthcare professional relationship (Day et al., 2005), the
side effects of antipsychotics such as pyramidal symptoms and sedation
(Dibonaventura et al., 2012; Eticha et al., 2015), patients beliefs about the effects
of medication (Higashi et al., 2013), psychological symptoms (Barkhof et al., 2012;
Higashi et al., 2013), patients awareness of the symptoms of their illness (Barkhof
et al., 2012; Higashi et al., 2013; Novick et al., 2015), and cognitive dysfunction
(Masand et al., 2009). Therefore, mental health professionals should implement
measures that have beneficial effects on these factors. In Japan, mental health
professionals are keenly aware of the importance of comprehensive ACCEPTED
MANUSCRIPT ACCEPTED MANUSCRIPT community psychiatric treatment based on
the bio-psycho-social model and have a strong interest in using psychosocial
treatment to improve the quality of life (QOL) of patients that are discharged from
hospital. In particular, psychoeducation about psycho-social treatment is widely
recognized to provide patients with psychological support and information about
their illness and medication, enable patients to share their experiences, and aid the
acquirement of coping skills, and it has been shown to be effective at empowering
patients with schizophrenia (The Japanese Network of Psychoeducation and Family
Support Program, 2000). Psychoeducation programs for patients with schizophrenia
have been shown to have the following positive effects: to induce improvements in
medication adherence (Xia et al., 2011; von Maffei et al., 2015), patients views
about medication (Hornung et al., 1998; Hayama et al., 2002), the acquisition of
condition-specific knowledge (Renri, 1995; Aho-Mustonen et al., 2010; Hasan et al.,
2015), patients awareness of the symptoms of their illness (Chien & Thompson,
2014), patients coping and social skills (Chien & Thompson, 2014), and QOL (Guo
et al., 2010; von Maffei et al., 2015) and to reduce the frequency of relapse and
rehospitalization (Pekkala and Merinder, 2009; Hasan et al., 2015) and the severity
of self-stigma (Uchino et al., 2012). However, psychoeducation is only performed in
approximately 30% of psychiatric institutions in Japan (Fukui, 2011). This might be
due to factors such as the difficulty of delivering psychoeducation in poorly
environmental conditions, as well as a lack of knowledge and skills regarding
psychoeducation among nurses and other medical staff and labor shortages at
psychiatric hospitals (in 2010 the numbers of psychiatrists and nurses per 100
psychiatric beds in Japan were 3.5 and 20.5, respectively) (Ministry of Health,
Labour, and Welfare, 2013)). Thus, a nurse-led version of a psychoeducation
program for patients with schizophrenia, the ACCEPTED MANUSCRIPT ACCEPTED
MANUSCRIPT Nursing Psychoeducation Program (NPE), was developed by Matsuda
(2008). In a previous study, the clinical usefulness of the NPE was evaluated using a
mixed-method research design. Qualitative data were collected using semi-

structured interviews and used to explain the process to which patients with
schizophrenia that were undergoing psychoeducation accepted their illness and the
need for medication, and quantitative data were collected in a one-group pretest/post-test study to assess the changes in the patients knowledge regarding
their illness and the effects of medication on it brought about by the intervention.
As a result, it was demonstrated that the program was useful for helping patients
accept their illness and the need to take medication and for improving the patients
condition-specific knowledge. However, a pre-experimental design was used for the
abovementioned quantitative research; consequently, there is insufficient evidence
to support the utility of the NPE. Therefore, we considered that it was extremely
important to use a quasi-experimental design to assess the usefulness of the NPE.
The objective of this study was to evaluate the clinical utility of the NPE for
inpatients with schizophrenia using a quasi-experimental design. In particular, we
focused on acceptance of medication and patients knowledge concerning their
illness and the effects of medication on it. Methods Study design This study was a
quasi-experimental study involving convenience samples, a non-equivalent control
group, and a pre-test/post-test design. Subjects ACCEPTED MANUSCRIPT ACCEPTED
MANUSCRIPT The study was performed at the acute treatment units of two Japanese
psychiatric hospitals run by the Department of Psychiatry. The acute treatment units
run by the Department of Psychiatry have to meet certain criteria established by
the Ministry of Health, Labour and Welfare, e.g., they have to discharge over 40% of
their patients within three months and employ appropriate numbers of medical
professionals. The subjects were recruited from among the patients that were
admitted to the abovementioned acute treatment units based on the inclusion and
exclusion criteria outlined below. The recruitment of subjects were conducted by
patients primary nurses and primary doctors. The inclusion criteria were as follows:
having being diagnosed with schizophrenia according to the International
Classification of Diseases - revision: 2013 (ICD-10: codes F20 to F25), being given
oral antipsychotic medication, being able to attend a one-hour session, being
capable of verbal communication, and being aged 20. The exclusion criteria for
the subjects were as follows: having an intellectual disability, refusing to participate
in this study, and being difficult to seat during the sessions. All of the patients who
met the inclusion criteria were invited to participate in this study. The patients who
agreed to participate in the study were assigned to either the experimental or
control group. The experimental group took part in the NPE, and the control group
received the current standard treatment for schizophrenia. Interventions The NPE is
a four-session intervention program covering four topics: the symptoms of psychotic
illness, the association between psychogenic illnesses and stress, the primary
effects and ACCEPTED MANUSCRIPT ACCEPTED MANUSCRIPT side effects of
antipsychotic medication, and how patients can learn to live with their illness in the
community. In each session, an original textbook is used as a learning material
(table 1). The textbook has five main sections: a) an illustration of the relationship
between psychotic illnesses, stress, antipsychotic therapy, and psychiatric
rehabilitation; b) discussion points about the patients past and current status; c) a

workbook about the primary effects and side effects of antipsychotic medication; d)
lists of questions and answers designed to allay patients fears; and e) changes
patients should make to their lives to prevent relapses. The sessions were
conducted once a week for 60-90 minutes (a total of four times) in a closed group
setting. The program was conducted by two psychiatric nurses (a leader and a coleader). The nurses who conducted the NPE sessions made a special effort to get
the patients to share their experiences of their illness, and to provide the patients
with psychological support. The nurses received training in the NPE in advance. The
training for the NPE took the form of the psychoeducational practitioner training
program (PPTP) developed by Matsuda and Kono (2015) and was conducted on two
consecutive days in a workshop style. The PPTP comprises three learning strategies:
lectures, audiovisual aids, and role-plays. In the lecture, the nurses received
explanations based on original learning materials (text and slides), and the program
developer provided explanations of how the program should be delivered whilst the
nurses watched a DVD about the NPE. Furthermore, the nurses also learnt the
theory behind the NPE (table 2). Data collection In both the intervention and control
groups, data were collected immediately before and after the intervention period
using structured questionnaires. However, the data regarding the subjects'
ACCEPTED MANUSCRIPT ACCEPTED MANUSCRIPT characteristics (except for the
antipsychotic regimens administered and the subjects Global Assessment of
Functioning (GAF) scores) were collected before the intervention. Instruments The
structured questionnaires used are described below. Subjects' characteristics The
following characteristics were examined: age, gender, the number of times the
subjects had been hospitalized, the antipsychotic regimens administered, and the
subjects GAF scores. Data regarding all of these characteristics were collected from
the patients' medical records by nurses. The GAF was completed by primary
healthcare nurses. The GAF includes two scales, which are used to evaluate
patients symptoms and functions. The GAF is a widely used scale and runs from 0
to 100, with higher scores representing better functioning. All antipsychotic drug
doses were converted to chlorpromazine equivalents. Primary outcome: Acceptance
of medication Medication Perception Scale for Patients with Schizophrenia (MPS)
This scale, which was developed by Matsuda et al. (2012), is used to evaluate the
degree to which patients with schizophrenia have accepted their illness and the
need to take medication. The MPS consists of a self-reported scale including 13
items and three sub-scales: 7 items for efficacy of medication, such as If I
continue to take antipsychotic medication, I think that can avoid rehospitalization;
3 items for worries about side effects, such as I seize with fear when thinking
ACCEPTED MANUSCRIPT ACCEPTED MANUSCRIPT about the side effects of
antipsychotic medication and I think that taking antipsychotic medication will
have adverse effects on my future children; and 3 items for fear of discontinuing
medication, such as I become anxious when I do not have medicine close at
hand and I am afraid about forgetting to take medicine. The patients were asked
to respond to each item on a 4-point Likert scale (1-4 points), with higher scores
representing greater medication adherence. The Cronbachs alpha coefficient for

this instrument had been reported to be .75 for efficacy of medication subscale, .
75 for worries about side effects subscale, .75 for fear of discontinuing
medication subscale, and .69 for the total scale (Matsuda et al., 2012). Drug
Attitude Inventory-10 Questionnaire This inventory is a modified version of the Drug
Attitude Inventory-30 Questionnaire, which was originally developed by Hogan et al.
(1983). Specifically, it is a shorted version of the original inventory containing 10
instead of 30 items. The DAI-10 is a self-reported measure in which patients are
asked to agree or disagree with various statements. The total score ranges from -10
to 10, with higher scores representing greater subjective responses to medication.
This inventory is commonly used to evaluate medication adherence in Japan. In the
current study, the Cronbachs alpha coefficient had been reported to be .73 for the
total scale (Shimodaira et al., 2012). Secondary outcome: Knowledge of psychiatric
illness and antipsychotic drugs Knowledge of Illness and Drugs Inventory; KIDI This
inventory was developed by Maeda et al. (1992) to assess patients knowledge
regarding their illness and the effects of medication on it. The KIDI comprises two
sub-scales: 10 items ACCEPTED MANUSCRIPT ACCEPTED MANUSCRIPT assessing the
patients knowledge of their illness and 10 items assessing the patients knowledge
of the effects of antipsychotic drugs. This inventory consists of a self-reported
inventory that asks patients to select the correct answer from three choices, with
higher scores representing greater knowledge. In the current study, the Cronbachs
alphas coefficient had been reported to be .83 for the total scale (Matsuda, 2008).
Data analysis Descriptive statistics were used to understand the characteristics of
the intervention and control groups. The independent samples t-test or chi-square
test was used to verify the homogeneity of the distribution of each characteristic
between the two groups. The intervention group who completed the program were
analyzed. Two-way factorial repeated measures ANOVA was used to evaluate the
effects of the NPE on acceptance of medication and the patients knowledge
regarding their illness and the effects of medication on it. The two factors were
group (intervention group and control group) and time (before and after the
intervention). The data were analyzed using SPSS 20.0 for Windows. Ethical
considerations This study was conducted in accordance with the Declaration of
Helsinki (2013) and with the approval of the institutional review boards of our
affiliated facilities. After the study contents had been explained to the subjects in
writing, each subject was asked to write their name on an informed consent form.
The following ethical considerations were taken into account in this study: (1)
decisions to consent should be made of the subjects' own free will; (2) the subjects
should not suffer ACCEPTED MANUSCRIPT ACCEPTED MANUSCRIPT any loss, even if
they do not consent to take part in the study or withdraw from the study after
initially consenting to take part in it; (3) completed questionnaires should be
labelled with serial numbers instead of names; (4) all personal information obtained
in the study should be strictly protected; (5) the study outcomes should be mainly
published in academic journals, and appropriate measures should be taken to avoid
the identification of individuals; (6) questions regarding the study or its outcomes
should be appropriately managed at all times; and (7) the collected data should be

deleted or destroyed using shredders at the end of the study. Results Subjects
characteristics The subjects were 56 schizophrenia patients who agreed in writing to
take part in this study. The final analysis included 24 patients for the experimental
group and 19 patients for the control group. All of the examined characteristics,
except age and the GAF score, exhibited similar distributions in both groups (fig.1).
The subjects characteristics are shown in table 3. Effects of the intervention In the
intervention group, the mean scores for all measurements were significantly better
after the intervention than before the intervention. During pre-/post-intervention
comparisons, the group x time interaction had a significant effect on the total MPS
score (F (1, 41)=24.85, p

Alcohol Outcome Expectancies and

Regrettable Drinking-Related Social
Behaviors
Eugene M. Dunne; Elizabeth C. Katz 2015
Consequences of College Drinking
Despite efforts by college and university policy makers to curb alcohol consumption
and subsequent negative consequences, college students continue to drink at
dangerous levelsapproximately 1 in 4 college freshmen will drop out or have other
academic consequences due to alcohol abuse and 1800 college student deaths can
be attributed to alcohol-related injuries each year (Hingson et al., 2009).
Considerable research has found a positive association between drinking and
involvement in high-risk behaviors such as illicit drug use, risky sexual behavior,
driving while intoxicated and aggressive behavior (Fromme et al., 1997; Giancola,
2002; Paschall, 2003; Bersamin et al., 2012). The significant attention paid to highrisk behaviors in the literature is well deserved, as these behaviors have serious
consequences for the drinker, other individuals and society as a whole.
Research has found that nearly half of college students report experiencing at least
one alcohol-related consequence (e.g. missed class, unplanned sexual activity,
injury), while nearly 20% report experiencing at least five consequences
(Wechsler et al., 2002). While high-risk behaviors can result in serious
consequences, research suggests that less serious outcomes tend to be more
commonly reported. In fact, the most frequently experienced alcohol-related

negative outcome was 'doing something regrettable' (Wechsler et al., 2002), rather
than drunk driving, violence, or other high-risk behaviors. Another study found that
blackouts were the most frequently reported negative consequence, while the
second most reported was social and interpersonal problems (Read et al., 2008).
Regarding the latter, it is unclear in the current literature what behaviors may lead to
social and interpersonal problems.
Intoxicated social interactions may be examples of behaviors that result in social and
interpersonal problems. If these interactions were regretted, they would be
consistent with literature finding regrettable actions to be highly frequent among
college drinkers (Wechsler et al., 2002). These behaviors may involve in-person or
electronic communications, such as calling or text messaging a friend or potential
sexual partner while under the influence of alcohol. Because they have the potential
to be regretted, these behaviors are referred to herein as 'regrettable social
behaviors.' Regrettable social behaviors may have serious implications for
interpersonal relationships and mental health among college students. Previous
research has shown that having a supportive social network can be a protective
factor against mental health issues via increased access to pro-social activities
(Kawachi and Berkman, 2001). More specifically, high-quality social relationships
have been shown to be negatively associated with depression (Teo et al., 2013) and
suicide attempts (Holma et al., 2010). Social isolation has also been found to be
associated with depression, anxiety and substance use (Chou et al., 2011).
Research on self-consciousness has found that individuals may be more likely to
withdraw from future social situations following an embarrassing situation (Froming,
Corley, and Rinker, 1990). If regrettable social behaviors are perceived as
embarrassing, they may similarly result in withdrawal from future social events and
negatively impact social support and related benefits.
Current mobile technology allows for a continuous stream of social communication,
which may further increase susceptibility to engage in regrettable social behaviors
while intoxicated. Examples of electronic forms of regrettable social behaviors
include the relatively recent phenomena of 'drunk dialing' or 'drunk texting'both of
which are defined on popular internet-based dictionaries (e.g. Wikipedia, Urban
Dictionary). Ferris and Hollenbaugh (2011) examined motivations for 'drunk dialing'
among college students and found that students often engaged in such behavior for
reasons such as entertainment, confession of emotion and sexuality. While these

reasons may serve as a benefit to an individual, such behaviors could also place the
individual at risk for experiencing embarrassment, distress or other social
consequences (e.g. loss of a friendship or romantic relationship). In addition to
phone calls, sending text messages while intoxicated is likely more common, given
the relative ease compared to calling. These text messages may take the form of
'sexting'the transmission of sexually explicit messages or images via cell phone
which has been found to commonly occur among young adults (Drouin and
Landgraff, 2012), and is associated with recent substance use and high-risk sexual
behavior (Benotsch et al., 2013).
Despite the emerging literature on intoxicated use of electronic communications,
less attention has been paid to understanding perceptions or consequences of these
social behaviors. Specifically, the studies on 'drunk dialing' and 'sexting' discussed
above do not indicate whether young adults experience negative outcomes, such as
regret or embarrassment, following these behaviors. Such negative outcomes from
in-person (e.g. 'hitting on an attractive person at a bar') and electronic forms of
socially risky behaviors have not been well described in the current literature and a
better understanding of incidence and perception may be beneficial to prevention
and treatment efforts.