A tool to evaluate proportionality and necessity in the use of restrictive practices in forensic mental health settings:
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RESEARCH ARTICLE
Open Access
A tool to evaluate proportionality and necessity in the use of restrictive practices in forensic mental health settings: the DRILL tool (Dundrum restriction, intrusion and liberty ladders) Harry G. Kennedy1,2* , Ronan Mullaney1, Paul McKenna1, John Thompson1, David Timmons1, Pauline Gill1, Owen P. O’Sullivan1,3, Paul Braham1, Dearbhla Duffy1, Anthony Kearns1,2, Sally Linehan1, Damian Mohan1,2, Stephen Monks1,2, Lisa McLoughlin1, Paul O’Connell1,2, Conor O’Neill1,2, Brenda Wright1, Ken O’Reilly1,2 and Mary Davoren1,2,4
Abstract Background: Prevention of violence due to severe mental disorders in psychiatric hospitals may require intrusive, restrictive and coercive therapeutic practices. Research concerning appropriate use of such interventions is limited by lack of a system for description and measurement. We set out to devise and validate a tool for clinicians and secure hospitals to assess necessity and proportionality between imminent violence and restrictive practices including de-escalation, seclusion, restraint, forced medication and others. Methods: In this retrospective observational cohort study, 28 patients on a 12 bed male admissions unit in a secure psychiatric hospital were assessed daily for six months. Data on adverse incidents were collected from case notes, incident registers and legal registers. Using the functional assessment sequence of antecedents, behaviours and consequences (A, B, C) we devised and applied a multivariate framework of structured professional assessment tools, common adverse incidents and preventive clinical interventions to develop a tool to analyse clinical practice. We validated by testing assumptions regarding the use of restrictive and intrusive practices in the prevention of violence in hospital. We aimed to provide a system for measuring contextual and individual factors contributing to adverse events and to assess whether the measured seriousness of threating and violent behaviours is proportionate to the degree of restrictive interventions used. General Estimating Equations tested preliminary models of contexts, decisions and pathways to interventions. (Continued on next page)
* Correspondence: [email protected] 1 National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin 14, Ireland 2 DUNDRUM Centre for Forensic Excellence, Department of Psychiatry, Trinity College Dublin, Dublin 2, Ireland Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material
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