1

Reducing Restrictive Practices to Control Aggressive Behaviors in Young Novel Psychoactive

Substance Users

Mimerose Lang

Fairleigh Dickinson University

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Table of Contents

Abstract………………………………………………………………………………………………………………………………… 3
Chapter 1: Introduction……………………………………………………………………………………………………… …4

Background of the Problem……………………………………………………………………………………. 4

Safewards Background and Evidence……………………………………………………………………… 5

Significance of the Problem……………………………………………………………………………………. 6

Picot………………………………………………………………………………………………………………………. 7

Purpose Statement………………………………………………………………………………………………… 7

Conceptual Definition of Seclusion and Physical Restraint……………………………………. 8

Operational Definition of Seclusion and Physical Restraint…………………………………… 8

Chapter 2: Critical Appraisal of the Evidence……………………………………………………………………. 9

Search Strategies……………………………………………………………………………………………………. 9

Hierarchy of Evidence ……………………………………………………………………………………………. 10

Literature Review …………………………………………………………………………………………………. 10

Synthesis of the Evidence ……………………………………………………………………………………. 16

Recommendation…………………………………………………………………………………………………… 18

References…………………………………………………………………………………………………………………………………19

Appendix A: Figure 1 ……………………………………………………………………………………… 24

Appendix B: Figure 2 …………………………………………………………………………………… 25

Appendix C: Synthesis Table ……………………………………………………………………………………. 26

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Abstract

Restrictive practices (RP), such as seclusion or physical restraint, are generally permissible in psychiatric

hospital units to control suicidal, aggressive, or violent behavior in acutely ill and psychotic patients.

These controversial practices persist despite a call for their reduction and ban. However, with the use of

novel psychoactive substances (NPS) in the mental health population, a wave of patients has been

presenting to the emergency room with unprecedented psychosis and aggression (Shafi et al., 2017). As

a result, these patients (who often present with psychosis) are restrained or secluded to manage these

behaviors (Brady et al., 2017). This situation runs counter to ongoing efforts to lower the rate of

seclusion and physical restraint. Therefore, this evidence-based project aims to reduce such restrictive

practices among novel psychoactive substance users in the detoxification unit.

Keywords: drug addiction, NPS, restrictive practices, seclusion, restraint, polysubstance abuse
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Chapter I

Introduction

The wave of NPS users displaying aggressive behaviors upon admission to emergency medicine

and psychiatric wards constitutes a real challenge to the seclusion and physical restraint reduction

program (Shafi et al., 2017). The prevalence of these restrictive practices remains high despite a call for

their reduction and ban—so much so that an average of 7% of people with mental health conditions are

exposed to restraint worldwide (Noorthoorn et al., 2015). According to psychiatric regulations and

policies, mental health workers should use seclusion and physical restraint only as a last resort when

patients become a danger to themselves and others. However, healthcare workers face serious safety

issues and are often compelled to use seclusion and physical restraint to manage such behaviors (Jalali

et al., 2020).

Background

Over the past decade, the phenomenon of abusing novel psychoactive substances (NPS) has

been on the rise (Jalali et al., 2020). These substances are a synthetic version of psychoactive drugs

designed to achieve homologous effects similar to those of illicit drugs (Hughes et al., 2018). Among

these are synthetic cannabinoids, cathinone, and psychedelic phenethylamines analogs, receptor

agonists of GABA-A/B, synthetic opioids phencyclidine-mimicking dissociative drugs, piperazines, novel

stimulants, many prescribed medications, natural psychoactive medicines, tryptamine derivatives, and

many performance-enhancing drugs (PED) (Schifano, 2018; Hughes et al., 2018). Popular NPS names

among their users are "bath salts," "legal highs," "research chemicals," or confusing labels such as "K2,"

"Spice," or "NRG-1" (Jalali et al., 2020). The use of these drugs may result in accidental death and severe

psychosis (Shafi et al., 2017). A study by Jalali et al. (2020) also reported unpredictable health

consequences such as liver damage, cardiac toxicity, kidney problems, and respiratory problems.
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The use of NPS is popular among all age groups, while the clinical presentation of their use

varies widely depending on the substance or dosage used and the combination of substances (Jalali et

al., 2020). Between 2007 and 2017, the United States (US) Poison Control Center received 4,597 calls

about exposure among adolescents (Ng et al., 2019). Another observational study by Jalali et al. (2020)

noted that not all NPS users presented with the same clinical symptoms or severity. In other words, the

symptoms would fluctuate depending on the type of NPS used. Users could experience a variety of

somatic and mental symptoms ranging from mild to severe. These physical symptoms might be cardiac,

vagal, gastrointestinal, or speech-related disorders. Mental symptoms might range from the

manifestation of simple deviations in behavior to positive symptoms reminiscent of schizophrenia,

psychomotor retardation, giddiness, disturbances of consciousness, or sometimes extreme verbal or

physical aggression (Jalali et al., 2020). Jalali et al. (2020) noted that of the 96 patients seen in the

emergency room, 36 patients presented with aggressive behavior. The authors found that staff

members generally controlled those who exhibited aggressive behavior through the use of seclusion and

physical restraint. Shafi et al. (2017) noted the high degree of aggressiveness among young-adult NPS

users, which indicates a more significant problem in managing drug-addicted patients. Another study

found that the emergency department received NPS users with much more disturbing clinical

presentations of acute psychosis, confusion, perceptual disturbances, agitation, and aggression (Shafi et

al., 2017). The study by Mento et al. (2020) further observed an unprecedented rise in the rate of

assaults directed toward emergency medicine and psychiatric care providers. Some patients and their

relatives, doctors, and other healthcare workers were assaulted, injured, or even murdered.

Safewards Background and Evidence

Bowers (2014) created the Safewards model. To fully understand this model, it is necessary to

understand the terminology of the Safewards. 'Conflicts' in this model are considered incidents related

to safety, such as assault, attempted self-harm or suicide, elopement, fighting, use of illicit substances or
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refusal to take medication, and more in this same category (Bowers, 2014). 'Containment' itself is

categorized as many issues related to staff interventions, such as routine medication administration, as-

needed medication, seclusion, physical restraint, or special observation (Bowers, 2014). 'Staff modifiers'

refer to the sum of staff interactions among staff team members or between staff team members and

patients. 'Patient modifiers' refer to reciprocal behavior between patients and staff (depending mostly

on the staff's influence) (Bowers, 2014). 'Flashpoints' are social and psychological events that occur in

'originating domains' (events that happened in psychiatric wards) that precede or signal impending

confrontational behavior.

Bowers established this method from a groundbreaking observation that some wards have low

containment (seclusions, physical restraints, and other interventional events) rates, while others have

high rates— despite being exposed to the same degree of conflict. Therefore, he proposed explaining

this difference in the conflict rates within wards through the Safewards model. He further detailed how

his model's different components influenced the dynamics of 'conflict and containment' (see figure 1).

This theoretical model presents ten interventions aimed at securing patient and mental health staff in

the wards by reducing conflict and containment. These interventions are theorized to amend potential

flashpoint events that might result from six originating domains: staff team, the immediate

environment, regulatory framework, the patient community, patient-related factors, and the outside

hospital. These areas can generate flashpoints, which can, in turn, trigger conflict and containment. Staff

interventions can alter these processes by reducing the underlying factors, stopping the occurrence of

flashpoints, and breaking the link between flashpoints and conflict. Staff achieves the goal of lowering

containment by avoiding conflict and ensuring that containment does not result in further conflict.

Overall, the model indicated that containment is dynamically correlated with conflict and that

sometimes the use of containment can give rise to conflict rather than successfully prevent it.

Significance of the Problem

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Seclusion and physical restraint in psychiatry are the most contested and controversial subjects

in the literature (Goulet et al., 2017). The use of these restrictive practices remains a challenge for

nurses in managing aggression among NPS users. Despite observed instances of aggression among this

population (Shafi et al., 2017), the reduction of seclusion and physical restraint is of extreme importance

to nurses in terms of ethics, patient rights, and minimizing the harmful effects of restraint (Raveesh et

al., 2019). Additionally, patients find these restrictive interventions to be psychologically traumatic

(Krieger et al., 2017). The physical consequences of seclusion and physical restraints can lead to severe

bruises and injuries, increased restlessness, and even death from strangulation (Brophy et al., 2017).

These coercive practices make organizations and healthcare professionals legally and financially liable

(Raveesh et al., 2019). It is important to decrease or eliminate the use of seclusion and physical restraint

in the NPS population. A decrease in the rate of seclusion and physical restraint will improve patient

safety, enhance the quality of care, and raise customer satisfaction.

PICOT Question

P — Population of interest: Staff treating patients 18–35 years old with dual-diagnosis, NPS users,

inpatients who admit to taking or are suspected of abusing NPSs

I — Intervention: Implementation of Safewards guidelines (Bowers, 2014)

C — Comparison: No Safewards guidelines 

O — Outcome: Decrease the seclusion and physical restraint rate to 10% in three months

T — Time: Three-month period

Picot Clinical Question

For staff (P) caring for young patients with aggressive behavior aged 18–35 years old on a

Detoxification Unit who have admitted to abusing or are suspected of abusing NPS. How does the use of

Safewards staff training (I) compare to not using Safewards training (C) to decrease the rate of seclusion

and physical restraint by 10% and promote quality of care and patient safety (O) over three months (T)?
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Purpose Statement

The purpose of this evidence-based project is to reduce the rate of seclusion and physical

restraint by 10% in patients aged 18 to 35 who admitted to taking or are suspected of being on NPS by

using the Safewards methods for three months.

Conceptual Definition of Seclusion and Physical Restraint

In this paper, seclusion can be defined as the voluntary or involuntary short-term isolation of a

service user in a specially designed room; generally, it is not very stimulating, is bare or poorly decorated

(seclusion room), and is locked from the outside. The staff may monitor patients through an observation

window (Green et al., 2018). Physical restraint is referred to in this paper as the strapping of a patient to

a bed with mechanical devices (belts). Bed belts go over the patient's arms, legs, and torso. Sometimes,

5-point restraints are used, but all belts are not always used all the time. 

Operational Definition of Seclusion and Physical Restraint

The number of single seclusion or physical restraint events will be counted over three months.
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Chapter II

Critical Appraisal of the Evidence

This evidence-based practice project aims to reduce the rate of seclusion and restraint by 10%

with staff training using the Safewards model (Bowers, 2014).

Search Strategies

In search of the best evidence, the following databases were queried: MEDLINE (via PubMed),

Embase, The Cochrane Library, Academic Search Premier, and PsycINFO Cumulative Index to Nursing

and Allied Health Literature (CINAHL). All selected studies are dated from January 1, 2015, to October 9,

2020, to reflect current practice. The query's main objective was to find the best evidence focusing on

staff training to reduce restrictive measures such as seclusion or physical restraint. Peer-reviewed

studies based on the above criteria were eligible for inclusion regardless of article type. All selected

articles were written in English. All geographic areas were eligible.

Keywords such as ('physical restraint' OR seclusion) AND (psychosis OR drug dependence OR

novel psychoactive substances (NPS) OR novel drugs OR legal high) were entered in the literature

search. The search for addiction articles revealed 200 articles, with 20 articles on NPS, suggesting that

the NPS topic is under-researched. The seclusion/restraint investigation generated 2,824 items related

to reducing seclusion and physical restraint, psychosis, aggression, violence, schizophrenia or drug-

induced psychosis, and personality disorders. Articles that strictly focused on patients with severe

schizophrenia, intellectual disabilities, geropsychiatry, and gerontic-psychiatry were excluded since SR

utilization pertains to patients with distinctive psychiatric and intellectual profiles.

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Articles on staff intervention aiming at reducing seclusion and restraint yielded 15 items and two

randomized controlled trials. As the research yielded more articles, it became evident that the concept

of aggression was a constant theme that merited further exploration. 

Hierarchy of Evidence

Polit & Beck's (2012) guide to evaluating quantitative and qualitative research was used to

determine the evidence's quality and strength. Additionally, the hierarchy of evidence proposed by

Melnyk & Fineout-Overholt (2011) was applied to determine each study's evidence levels (1995).

Literature Review

Seclusion and restraint are interventions used as safety measures to manage aggressive patient

behavior among those at serious risk of self-harm and harm to others (Hughes et al., 2018). However, in

the current patient-centered healthcare delivery model, debate and controversy remain concerning the

practices of seclusion and physical restraint. It also remains a challenge to overcome for the NPS user's

population displaying aggressive behavior.

Shafi et al. (2017) conducted a quasi-experimental design study (level two evidence) on the

risk of violence associated with the misuse of NPSs among patients presenting to London's acute mental

health services. This study looked at the impact of NPS misuse on patients admitted at an acute mental

health facility in London. With a study sample of (N = 442) admissions who presented to the emergency

room, the authors found that the study participants were more likely to be male and young and have

had a history of previous hospitalizations for medical or mental health issues. The use of all illicit

substances (amphetamine, opiate, and cocaine) was more common in the group using NPS, and it was

significantly associated with NPS use (p < .001). Moreover, the authors noted that violence before and

during admission is considerably higher among NPS misusers than non‐NPS substance abusers. Also, the

higher rates of aggression among NPS users make it more challenging to safely manage this population.

This study is one of the first to provide insight into these group behaviors. They suggest several
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management strategies to deal with health and behavioral disturbances. The need to use a robust

psychiatric care model also clearly emerges from this study to reduce seclusion and physical restraint as

a tool to manage aggression in this unique population.

Goulet et al. (2017) conducted a systematic level one review to evaluate studies related to

seclusion and physical restraint. Using the Cochrane risk-of-bias tool (2005), the authors reviewed 23

articles that explore this issue. These articles evaluated how program protocols — leadership, staff

training, post-seclusion and restraint use assessment, patient engagement, prevention measures, and

the therapeutic environment — reduce the need for seclusion and physical restraint. They were carried

out in the US, Australia, the Netherlands, the United Kingdom (UK), Sweden, and Finland at mental

health hospitals. According to the Cochrane risk-of-bias tool, these studies showed a considerable risk of

bias due to the limited amount of evidence presented and the flaws in these studies' research design.

Such as risk-of-bias tool randomization procedures, blinding of participants and personnel, incomplete

outcome data, and other biased sources. Of the 23 studies, only one — the Safewards model — had a

randomized controlled trial (RCT). The majority of studies only reported pre- and post-descriptive data

without any statistical or control group comparisons.

Goulet et al. (2017) acknowledged that the Safewards model stands out as a study with a

scientific and theoretical basis. This review's limitation is the systematic review's inherent difficulty in

comparing studies with different patient populations, outcomes, and interventions. However, due to the

heterogeneity of identified outcomes, the authors did not assess the risk of bias across studies

(measures of consistency, heterogeneity, and funnel plot with Egger's test). This systematic review's

strength is to summarize the evidence from 23 studies on reducing seclusion and physical restraints

providing level one evidence. This study concluded that the Safewards model is a robust and promising

scientific tool (the only RCT) that could make psychiatric wards safer.
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In 2014, Bowers laid the groundwork for a new model called "Safewards" in the UK by observing

a disparity in the rate of containment (staff interventions) and conflicts (safety issues) in psychiatric

wards that had the same rate of safety incidents. In the Safewards model, containment is detailed as an

approach that staff can take to avoid conflict (e.g., as-needed medication, special observation, seclusion,

restraint, de-escalation, and more). Conflicts are serious safety issues that affect the patient and staff

(violence, suicide, self-harm, absconding). This theoretical model presents ten interventions that are

very similar to each other and aim at securing patient and mental health staff in the wards. These

interventions mitigate potential flashpoint events resulting from six originating domains: staff team, the

immediate environment, the regulatory framework, the patient community, patient-related factors, and

the outside hospital. These areas can generate flashpoints, which can, in turn, trigger conflict and

containment protocols. Staff interventions can prevent the occurrence of flashpoints, breaking the link

between flashpoints and conflict; if staff members can avoid conflict, containment becomes

unnecessary, breaking the cycle of conflict-containment. Unlike other models aiming to reduce the need

for containment, this model is uniquely comprehensive. It looks at many of the factors that allow staff to

act preemptively and avoid initiating containment protocols. Specifically, this model focuses on the six

domains that are patient-related and are often the source of conflicts in the wards. This model would

help situations like patients' copying disruptive behaviors others might exhibit, staff members'

responding to a patient's disruptive behavior, triggers in the patient's personal life, the maintenance of

the environment (calls for quick repair), and acceptable promotion-regulatory practices.

 In subsequent work, Bowers et al. (2015) tested the Safewards model's effectiveness by

creating a level two quantitative randomized controlled trial (RCT) study. The study aimed to reduce

conflict and containment in adult acute psychiatric wards. The authors wanted to create conditions to

make psychiatric wards safer and less coercive. This study was an experimental cluster sampling design

that included 31 randomly selected psychiatric wards in 15 selected hospitals (Bowers, 2014). In this
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study, the overall 'containment' (which included physical and chemical restraint) was reduced by 26.4%

in intervention wards. This study is a unique contribution to the seclusion- and physical restraint–

reduction issue since no RCT has ever been attempted before. This study's limitation is its restricted

generalization. The study took place in the UK within its’ healthcare systems. Consequently, the

psychiatric care can vary widely. 

Dickens et al. (2020) evaluate how conflict, containment, and violence prevention are affected by

implementing the Safewards model in large metropolitan-mental health local departments in New

South Wales, Australia. The authors used a pre-and post-test longitudinal study design. In total, nine

(N = 9) psychiatric departments participated in the study. The authors used the PCV-14 change ratio to

measure the patient-staff conflict checklist and the climate of violence. Despite the climate

assessments of violence prevention persisting, containment decreased by 23% and conflict by 12%.

This finding suggests that Safewards is one of the few acceptable interventions capable of reducing

the containment rate or any staff action to maintain safety. Safewards is associated with significant

improvements in all conflicts and containment incidents. Psychiatric services that opt against using

this intervention risk relying on unproven alternatives. Unfortunately, this study's small sample size

makes generalizing difficult.

To survey inpatient mental health professionals' views and experiences, Hughes et al. (2018)

conducted an exploratory study of novel psychoactive substance use by patients. With an online

convenience sample (N = 98) of health professionals, the authors noted that every participant reported

knowing patients who used NPS before admission. More than 90% of participants reported observing at

least one unwanted effect due to NPS use in the previous month, and 65% reported observing health

deterioration, 61% witnessed patients needing an emergency response, 84% observed mental

deterioration among patients, and 77% dealt with aggressive behaviors. Most participants stated that

patients still used NPS during their inpatient stay. The respondents' interventions for inpatient NPS-users
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included suspensions from wards, property searches, seclusion or segregation, detention under mental

health acts, and specific urine tests for corresponding NPS. Three-quarters of these mental health

workers were unaware of NPS's policies in their workplace. Participants reported lacking the knowledge

and skills to deal with their NPS patients. The findings suggest that NPS is prevalent among the mental

health population and that staff observe its adverse effects. Mental health workers in this study also

mentioned that the phenomenon of NPS made the ward less safe. Although this study is not

generalizable due to its methodology, this qualitative article is the first to document nurses' experiences

working with NPS patients, which would be valuable to this evidence-based project.

Spinzy et al. (2018) explored inpatient attitudes on using restrictive practices via a structured

questionnaire. The authors interviewed 40 hospitalized patients (N = 40) diagnosed with psychiatric

disorders. The results were controversial, as 77.5% of hospitalized patients reported that physical

restraint evoked loneliness, and 82.5% say they experienced a loss of autonomy; also, 73.6% of

hospitalized patients considered staff visits during physical restraint to be beneficial. Two-thirds of the

participants felt that the use of physical restraint was justified in violent situations. Two-thirds of

hospitalized patients viewed this experience as the most aversive of their hospital stay. The results of

this study demonstrated ambivalence about the use of restrictive practices. Participants suggested that

staff members should visit them during this challenging time, especially their case manager. They also

wished to have some control over television programming, lighting, and music while in seclusion. This

study is limited by its sample size of inpatients (N = 40) in that it only examines a single hospital.

However, it explicitly proposes a new way to deal with seclusion without causing additional trauma.

Green et al. (2018) used a convenience sample of 12 registered nurses who placed patients in

seclusion during the previous 12 months. These nurses were currently working in a forensic psychiatric

unit. The facilitator in this study organized them into a qualitative focus group. The authors used

thematic analysis and interpretive description. Four themes emerged from the discussions: seclusion as
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a last resort, presentation of aggressive behavior, organizational influences, and professional judgment.

Participants described the need to reduce the reliance on seclusion and the problematic nature of its

use as an ongoing intervention. This study identified a need to reduce restrictive practices and evaluated

its usefulness as an intervention in contemporary mental healthcare. The fact that the two focus groups

were composed essentially of registered nurses with extensive experiences in mental health locked

wards might limit these findings. A study with recent graduate nurses should be attempted in this type

of research to allow unbiased results. Another limitation of this study is the sample size and the small

geographic delimitation of this sample, which does not reflect other wards' cultures.

Jalali et al. (2020) carried out an observational study in Poland after observing many NPS

abusers being admitted to Poland's emergency departments. The undetectability of NPS by standard

screening tests makes appropriate therapeutic intervention difficult. Therefore, the researchers sought

to assess the characteristics of NPS users (adults and children) and formulate a diagnostic and treatment

protocol. They used a retrospective analysis of patients' medical records admitted to the emergency

room (ER) and pediatric emergency room (PED) between 2013 and 2018. They assessed the mental

status and laboratory diagnostic tests using medical assessment parameters such as Glasgow Coma

Scale (GCS), Pediatric Early Warning Score (PEWS), and the National Early Warning Score (NEWS). To

make their calculations, they used chi-squared, the Mann-Whitney U test, and the Shapiro-Wilk test.

The authors found that the numbers of adolescents using NPS were higher between 2013 and

2016, and the number decreased in subsequent years. The number of adults admitted to the emergency

department due to NPS increased significantly in 2017–18. NPS misuse was significantly higher in men,

dual diagnosis patients, alcoholics, patients diagnosed with mental health issues, and adolescents with

socioeconomic and family problems. Although they found coordination and aggression disorders in

pediatric patients, tachycardia and aggressiveness were primarily seen in NPS users' adult population.

Laboratory tests of adult NPS users mainly showed leukocytosis and ketonuria. Among symptomatic
 16
study participants, fluid therapy with sedation was, in most cases, adequate to resolve the patients'

symptoms within 48 hours.

Haugom et al. (2019) used qualitative content analysis to interpret seclusion episodes'

descriptive data (N = 149) in 57 psychiatric wards. These episodes were described by staff using a semi-

structured interview form. A few of the study participants revealed that seclusion is often used with

physical restraint to control violent and aggressive behaviors. Violence and assault are common in

mental health facilities, and mental health professionals must deal with violent situations. The study also

found that aggressive behavior leaves staff with a series of difficult decisions on seclusion or physically

restrained patients. Researchers found that the ethical challenges involved four fundamental ethical

principles: autonomy, beneficence, non-maleficence, and justice. They further noted that dealing with

seclusion or physical restraint would place a psychosocial strain on staff. This study's limitation resides in

the form of data used. The semi-structured data is less robust than structured interview data, as it tends

to be superficial and ambiguous. This study's strength is the first qualitative study on staff experiences

that address restrictive practices' ethical dilemma. In conclusion, this study addresses the ethical

question that mental health workers face.

Synthesis of the Evidence

The existing literature suggests a general movement toward reducing or prohibiting seclusion

and restraint in the client-centered health system (Green 2018). Green et al. (2018) further argued that

this practice is reminiscent of the late 18th century when the patient was shackled in handcuffs.

Therefore, these researchers felt that this practice violated fundamental human rights. Green et al.

(2018) also claimed that seclusion and physical restraint could lead to serious adverse effects in patients.

The adverse events include physical injury, feelings of anger and fear, flashbacks, and a weakened

relationship between patients and providers.

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Spinzi et al. (2019) explained that some patients viewed physical restraint as the most horrific

aspect of their psychiatric hospitalization. Worse yet, staff who physically restrain patients can be hurt

and feel emotionally uncomfortable (Spinzi et al., 2018; Haugom et al., 2019). In the case of an accident,

organizations can also be held financially and legally responsible for workers' compensation and patient

lawsuits (Frierson & Josh, 2019). These are just some of the reasons many patient advocates call for the

reduction and prohibition of seclusion and physical restraint (Green et al., 2018). Many have also

questioned its usefulness; Goulet et al. (2017) argued that the latest Cochrane review indicated that the

therapeutic value of seclusion and physical restraint had never been demonstrated. The question

remains: why is it still used as a clinical tool in managing aggression? However, new psychoactive agents'

growing popularity has complicated ongoing efforts to reduce seclusion and restraint in general (Jalali,

2020). Many alternative care models have been tested for other populations exhibiting aggressive

behaviors, but none have been implemented to manage this unique population safely. Sometimes NPS

users display aggressive behaviors (Hughes et al., 2018; Jalali et al., 2020; Shafi et al., 2017), which often

required seclusion and physical restraint (Jalali et al., 2020; Shafi et al., 2017). This ongoing practice

should only be used in the most extreme circumstances (Green et al., 2018), but too often served as a

control tool against NPS users' aggressive behavior. The frequent use of restrictive practices among NPS

users poses significant problems. If left unresolved, these practices can reduce care quality and destroy

the therapeutic relationship between patients and staff (Green et al. (2018).

Sometimes, NPS users are polysubstance users and mentally ill (Jalali et al., 2020; Shafi et al.,

2017). According to Shafi et al., 2017, this population has a higher incidence of readmissions, and in

some cases, death is possible (Jalali et al., 2020). Besides, NPS is associated with violence before and

after admission (Jalali et al., 2020; Shafi et al., 2017); comorbid health conditions (Jalali et al., 2020) such

as kidney failure, liver toxicity, and heart and respiratory problems (Jalali et al., 2020). The risk of

aggression in NPS users poses challenges that require a solution to targeted care for this population.
 18
Due to this new wave of assault, health workers are concerned about the overall safety of psychiatric

services (Hughes et al. 2018).

However, it is in health workers' interests to use the least restrictive measure to ensure this

population's safety. Acting preventively to avoid injury could make this possible. There are even

accidental death cases when physical restraints are used (Green et al., 2018). Workers and healthcare

organizations should exercise caution when physically secluding or restraining NPS users, as they are

prone to health comorbidities that can lead to sudden death.

Many psychiatric care models cited in the current literature aim to reduce seclusion and physical

restraint by establishing a program protocol. These protocols include leadership, staff training, post-

isolation examination, patient engagement, preventive measures, and the therapeutic environment.

However, these care models reported only pre- and post-descriptive data without a statistical

comparison or control group (Goulet et al., 2017). Except for Safewards and Six Core Strategies, Goulet

et al. (2017) reported little evidence to support these alternatives' effectiveness in reducing seclusion

and physical restraint. Safewards is the most robust scientific model tested in a randomized controlled

trial (RCT) (Bowers et al., 2015).

Recommendations

The available evidence indicates that the use of NPSs is common among patients with mental

conditions. However, most healthcare providers lack the necessary knowledge and skills to manage NPS

use in their patients, are unaware of NPS policy at their workplace, and want access to specific NPS

information and training. Thus, the first recommendation is to ensure access to reliable and up-to-date

information on changing substance use trends for mental health professionals treating NPS patients.

Hospital policies need to include guidance on the safe clinical management of substance use, including

NPS. Second, the Safewards model is one of the best‐evidenced nursing interventions for containment

and conflict reduction that is promising in reducing the rate of seclusion and physical restraint for this
 19
project. Future interventional studies and quality improvement initiatives should also test and

implement this model in various mental settings, especially for the young NPS users displaying

aggressive behavior.

 
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Appendix A

Figure1. Figure Depicting the Safewards Model in its Simplest Form

From: (Bowers, 2014)

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Figure 2

Figure Depicting the Level of Evidence

From: Reference.
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