Daytime night attire as a therapeutic intervention in an acute adult psychiatric in-patient unit

AIMS AND METHOD

Dressing in-patients in night attire during daytime is currentlypractised in many in-patient psychiatric units, despite thelack of evidence to support its benefit in reducing abscondingor self-harm. Using a triangulation design, we investigatedthe prevalence of, attitudes towards and associations of this practicein an acute psychiatric in-patient setting in the Republicof Ireland.

RESULTS

Case-note review revealed a high prevalence of this practice(57%) and its significant association with involuntary admission.Nursing staff believed that using night attire was effectiveat reducing absconding and self-harm, and that only voluntarypatients should retain the right to choose their clothes. Mostpatients interviewed were uncomfortable in night clothes and indicated that they should be entitled to choose what to wear.

CLINICAL IMPLICATIONS

Night attire is regularly used for risk-management, despitelack of evidence supporting its efficacy and negative attitudestowards it in many patients. This practice and the reasonsfor its implementation deserve medical documentation.

Introduction

TOP

Introduction

Restraint and restriction of in-patients with mental illnessis not new, as early asylum care depicts patients chained towalls and denied clothing (Belkin, 2002). Although care inIrish psychiatric hospitals is far removed from this, many openacute psychiatric in-patient units maintain a policy of placingnewly admitted patients, both voluntary and involuntary, innight attire and withholding their day clothes, apparentlyfor the purposes of reducing absconding and self-harm.

Insistence on night clothes is perceived by some patients asa means of controlling and restricting their freedom (Wallace et al, 1999).It may contribute to institutional neurosis (Barton, 1959)and is arguably contrary to Articles 1, 5 and 9 of the UniversalDeclaration of Human Rights (United Nations, 1973) and Article3 of the European Convention on Human Rights (Council of Europe, 1950).More recently, Article 9.1 of the Council of Europe Committeeof Ministers recommendations to member states concerning theprotection of the human rights and dignity of persons withmental disorder (Council of Europe, 2004), states that theenvironment and living conditions of persons with a mental disordershould be equitable, in so far as is possible, with those ofpersons with similar age, gender and culture in the community,a recommendation which is not fully adhered to by the use ofnight attire in this context. The diagnostic inquiry on thehuman rights of persons with mental disorders in Central Americaconsidered that keeping patients in pyjamas violated their rightto quality of life (Levav & González Uzcátequi, 2000).The use of night attire to prevent absconding is neither supportedby literature reviews (Bowers et al, 1998), nor part of recentlyimplemented anti-absconding interventions (Bowers et al, 2003; Bowers et al, 2005).

Gray & Higenbottam (1982) reported widespread placementof patients in pyjamas despite their being ambulatory and not acutely ill, in order to facilitate physical examinations andmanage rule infractions. They recommended that the efficacyof this practice requires demonstration in light of associateddehumanisation, demoralisation and negative therapeutic relationships.Such work has not yet appeared in the literature on the subject.

This study aims to identify the prevalence of placing patientsin night attire, its clinical and demographic associations,and the attitudes of patients and nursing staff towards it.

Method

TOP

Method

We used a triangulation design incorporating data from medicalcase notes, questionnaires completed by nursing staff and interviewswith in-patients in an open acute psychiatric ward in a localgeneral hospital in Ireland.

We reviewed medical and nursing notes relating to all admissionsover a 6-month period, generating a sample of 185 patients.Data were collected on age, gender, diagnosis, legal status,length of admission, documentation relating to placement ofthe patient in night attire, whether this was requested inwriting, and whether reasons were documented for making this request.

An anonymous questionnaire was posted to all 35 members of nursingstaff working in the unit to ascertain their attitudes towardsplacement of patients in night clothes. Thirty-five in-patientswho had made the transition from night attire to day clotheswere also interviewed to assess their attitudes. The patientquestionnaire confirmed that they were asked to hand in day clothes on admission, their reactions to this and their beliefsregarding the right to choose their clothes. (Copies of thequestionnaire available from the authors.)

Ethical approval for the study was granted by the Galway University Hospitals Clinical Research Ethics Committee. Data was analysedusing SPSS version 12 for Windows, with ${chi}$ ² analysis for clinical associations of nominal variables.

Results

TOP

Results

Data from admission notes
Of the 185 admissions, 100 were men (54%); 33 patients (17.8%)were admitted involuntarily and the mean age of the samplewas 44.4 years (s.d.=14.7). The mean length of stay was 25.4days (s.d.=34.7).

The ICD–10 diagnoses of all patients were recorded ondischarge: 42.7% patients had moderate depression, 13% hadmanic bipolar disorder, 13% paranoid schizophrenia, 9.2% depressedschizoaffective disorder, 4.9% alcohol dependence, and otherICD–10 diagnoses represented in smaller proportions.Less than half of the patients in the study (42.7%) were referred to the unit from primary care, 18.9% were self-referred, 18.9%were referred by community psychiatrists, 7% by community mentalhealth nurses, 6.5% by general hospital wards, 4.3% by accidentand emergency, and 1.6% by police.

As many as 106 patients (57.3%) were placed in night attireat the time of admission, a process recommended by doctorsin 59 case notes (55.7%), although only 3 case notes (2.8%)contained a documented reason for doing so. The mean proportionof overall admission time spent in night attire was 41% (s.d.=23).

The associations of being placed in night attire are shown in Table 1. There was a statistically significant associationbetween being admitted involuntarily and being placed in nightattire ( ${chi}$ ²=7.58, d.f.=1, P=0.006), but no significant associationwith gender or a diagnosis of psychotic v. non-psychotic illness.

View this table:
[in this window]
[in a new window]

Table 1. Clinical associations of placement in night attire

Survey of nursing staff
Completed questionnaires were returned by 27 staff (a responserate of 77%), of which 81.5% were staff nurses and the restnurse managers. The majority of respondents were women (n=19,70.4%). The mean age was 35.7 years (s.d.=9.9) and the meanlength of service was 14.3 years (s.d.=9.4).

The perceived reasons by nursing staff for placing patientsin night clothes are outlined in Box 1; most of them thoughtthat this would help reduce the risk of absconding or self-harm.

The majority of staff (77.8%) believed that night attire waseffective in addressing their chosen reasons. However, 48.1%of nursing staff described the practice as detrimental throughloss of independence, enforcement of the sick-role, loss ofdignity, increased agitation, punitive associations, institutionalisation,reduced trust in therapeutic relationship and coercive practice.As many as 81.5% of nursing staff believed that choice of attire should be afforded to voluntary patients, whereas only 14.8%thought that involuntary patients should be allowed this choicetoo. Nursing staff commented that night attire was ‘usefulfor determining a patient’s willingness to remain inthe unit,’ and that it ‘allowed time for staffto assess a newly referred patient and to evaluate whetherthe patient was at risk of absconding’.

Box 1. Reasons identified by nursing staff for placing patientsin night attire

To reduce the risk of deliberate self harm,16 (59.3%)

To deprive the patient of privilege, 2 (7.4%)

Toreduce the risk of a patient absconding from the ward, 24 (88.9%)

Other,8 (29.6%)¹

1. ‘Other’reasons included: ‘hospitalpolicy’, ‘tradition/ritualistic practice’,‘monitoring of a patient’s whereabouts’ and‘encouraging rest’.

Patient survey
Data were obtained from 35 patients, 20 of whom were male; meanage 38.7 years (s.d.=10.0). More than half of the interviewedpatients (68.6%) reported feeling uncomfortable in night attireduring the daytime. Reasons given included embarrassment andhumiliation, lack of privacy, futility of the process, restrictedability to move around the ward, awkwardness, punitive associationsand being easily identified as a psychiatric patient. A significantmajority (80%) believed that they should retain the right to choose their clothes, 11.4% thought that they should not begiven a choice and 8.6% remained unsure.

Patients commented that ‘wearing pyjamas marks you out,makes you feel more depressed, and I just don’t see thepurpose, it wouldn’t stop me leaving if I really wantedto,’ ‘I have no privacy in pyjamas, it is quitehumiliating really,’ although another patient felt that‘I don’t mind it really, it helps me to rest’.

Discussion

TOP

Discussion

This study demonstrates a high prevalence of the use of nightattire in an in-patient unit, with medical documentation forthis practice rarely provided. Absconding is a significantconcern and is linked to risk of harm to self and others (Crammer, 1984; Sheppard, 1996). Patients abscond for several reasons, includingfeeling bored, frightened, trapped, confined and isolated fromfamily/friends (Bowers et al, 1999). Studies investigatingefficacy of reduced ‘restrictive’ care practicesand subsequent absconding rates report conflicting results (Cancro, 1968; Gudeman et al, 1985; Molnar et al, 1985), although a recentimplementation of an anti-absconding package demonstrated reducedabsconding rates (Bowers et al, 2003; Bowers et al, 2005).Elements of this package included a sign-in book for patients,supportive breaking of bad news, debriefing of patients regardingward incidents, multidisciplinary review, identification ofpatients at high risk of absconding, targeted nursing timedaily for those patients and facilitation of social contact.Placing patients in night attire is not documented as an effectivepart of any anti-absconding package, and may represent a formof conflict-generating preventive containment (Bowers, 2006).

In-patient prevention of self-harm has traditionally involvedmaintenance of physical safety, although the use of no-harmcontracts with patients and a one-to-one observation of a patientby a nurse have not had a significant impact here (Drew, 2001; Potter & Dawson, 2001). Data from an Irish qualitativedescriptive study investigating the intervention and preventionstrategies used by eight psychiatric nurses when working withnon-suicidal self-harming in-patients revealed that the practice of placing patients in their night clothes is followed in orderto attempt to ensure safety, although the staff remained unsureof the rationale or efficacy associated with this intervention (O’Donovan, 2007). The National Institute for Healthand Clinical Excellence guidelines recommend involvement ofpeople who self-harm in all discussions and decision-making regarding their care (National Institute for Health and Clinical Excellence, 2004),and there is evidence that perceived respect for patient’sautonomy is associated with self-reported improvement in mentalhealth (Kjellin et al, 1997; O’Brien & Golding, 2003).

Our findings reveal conflicting views of nursing staff and patients regarding the effects of having to wear night clothes at daytimeand the rights of patients to choose their daytime attire.The recently implemented Irish Mental Health Act 2001 statesthat ‘due regard shall be given to the need to respectthe right of the person to dignity, bodily integrity, privacyand autonomy’ (Office of the Attorney General, 2001),implying that involuntary admission is not synonymous withcomplete surrender of rights. Furthermore, removal of day clothesfrom voluntary patients could be considered an insidious formof detention which breaches current mental health legislation.

Strengths of this study include the triangulation design whichcombined qualitative and quantitative data from a large completesample of written case notes, a high response rate to questionnairesfrom nursing staff, and participation by a representative sampleof patients. However, these findings may not generalise toclosed wards, where different attitudes and usage of interventionsmay exist.

These findings demonstrate that night attire is used for a substantial proportion of in-patients despite the lack of evidence to supportits usefulness as a therapeutic intervention to protect againstabsconding or self-harm. Its use may fuel conflict betweenstaff members and patients given the apparently disparate attitudestowards its use by the two groups. Staff should consider alternativemechanisms in order to manage risk in a manner that would bemore acceptable to patients and more respectful of their dignity and autonomy. We suggest that, when psychiatrists recommendthat patients be placed in night attire, due attention shouldbe given to the fact that some patients may perceive this asundermining their autonomy and the decision and reasons forit should be documented in the medical notes.

References

TOP