Strengths Model-Based Nursing Interventions for Inpatients in Psychiatric Inpatient Settings Using a Seclusion Room: A Case Series Study

Round 1

Reviewer 1 Report

Thank you for the opportunity to review this manuscript.

 In this study, the authors aimed to verify whether the period of coercive measures was shortened by a nursing intervention based on the strengths model for psychiatric inpatients who were secluded over a long period. The participants were eight inpatients who used the seclusion room over a long period. Nursing interventions based on a strengths model were implemented in collaboration with nurses from six long-term care units in three psychiatric hospitals in Japan. 

The results revealed the number of days without seclusion increased in five cases following the intervention. Seclusion time decreased by 20.0%–45.0%, with an average decrease of 9.6%. Open observation time was increased by 1.4 hours per day on seclusion days.

 

 

 

The introduction needs a research question. 

The cited references are relevant to the research. 

The research design may be appropriate but needs another study design for the generalizability of the findings. And the data collection was in 2017.

The results are presented, but I think I understand the description of the data collection, but I was hoping you could explain it better.

The results support the conclusions, but maybe Such a conclusion cannot be made based on an exploratory study with few cases.

 

After controlling the attached paper with minor revisions, 

I recommend that the paper can be published in the journal.  

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Introduction

Several sentences are confusing.  The introduction should be more compact, it seems to be the discussion section.

 

Methods

 This section should be reorganized. Several sentences are confusing.

 

Results

 

It is important that a section will be included where more detailed information is provided about the diagnosis and other data such as the use of medication.

 

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 3 Report

Title: Effects of strengths model-based nursing interventions on coercive measures for inpatients in psychiatric inpatient settings using a seclusion room: a case series study

Thank you for the opportunity to review this manuscript for Nursing Reports. This case series study takes on a very important topic in mental health nursing and was a very informative international perspective on the use of coercive measures such as seclusion and restraint in Japan. The authors make a strong case for the need for improved interventions to reduce the use of these measures. Here I provide several comments and suggestions that I believe would strengthen this work:

Major issues:

11)     Methods section (2.3): I am having a hard time understanding what exactly the authors’ intervention is, why it qualifies as “strengths-based,” and how it relates to the reduction in use of seclusion they propose. I would recommend some additional information of previously developed interventions that qualify as “strengths-based” and what sort of education is provided to nurses to support this.

22)      The authors indicate that they and the nurses determine what each patient’s strengths are and then design interventions that incorporate these findings. However, the interventions described in column 1 of Table 6 do not seem to map very closely to the findings and seem much closer to providing rewards and behavior modification approaches.

a.       One suggestion would be to revise and condense the content in Tables 5 and 6 to clearly identify what the strengths are and reduce the additional details provided.

b.       In addition, I believe that not including patients in the discussion of identification of strengths is a major consideration (which the authors identify in their limitations section). It seems appropriate to include a fuller discussion of this decision not to include patients in the methods section and a description of how the nursing staff collected the data that were ultimately used.

33)      Results section

a.       Section 3-5-2/Line 267: “Non-directive and equal relationships lead to inpatient insight into intense emotional experiences.” The authors discussion of this section is quite limited and seems disconnected from their findings. The use of restrictive measures is very strongly opposed to a “non-directive and equal relationship,” and so this challenging area merits additional discussion.

44)      Discussion section: it seems important to point out that by virtue of conducting this study, the authors were identifying a problem with overuse of seclusion on the inpatient unit. Is it possible that by introducing this focus, nurses tried consciously to reduce utilization of seclusion? Could this be responsible (at least in part) for the findings?

a.       Line 288: I am having difficulty interpreting “None of the inpatients in this study were always mentally stable, and their mental states were disturbed by care that utilized their strengths.” Please consider rewriting to improve clarity.

55)      Conclusion section: The first line of the conclusion is overstated based on the study design. It does not seem appropriate to state “as a result” since there are many uncontrolled variables involved in the change in outcome observed.

Minor issues:

11)      Figure 1: The meaning of these titles are unclear to me: "Collaborative relationship building considering moderate stimulation of strengths"; “Ascertaining the degree of inpatient’s agitation caused by stimulating strengths” – I would recommend rephrasing these because I don’t know how to interpret

22)      Title: Too long and unclear. Coercive measures and seclusion room are redundant so maybe remove one?

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 4 Report

This is an exceedingly well researched and written manuscript on a topic that remains as one of the challenges of in-patient psychiatric care. The numbers cited for coercive measures are very different than in North American and other cultures, and are important for publication. One aspect that could be further strengthened is a brief deeper discussion of the cultural background that prompts these high and lengthy percentages of coercive measures, to help the reader understand the reasons behind these measures. Overall, the depth, research soundness, and presentation are excellent!

Author Response

Thank you for your careful peer review of our article. Thank you for your help in improving the quality of this research. As one of the factors behind the lengthening of the seclusion period, we described that it is based on the nursing intervention that focused on the patient's problem behavior, which was performed before the introduction of the strength model. Thank you very much.

Round 2

Reviewer 3 Report

Please see attached.

Comments for author File: Comments.pdf

Author Response

Please see the attachment.

Author Response File: Author Response.pdf