Restraint and restriction of in-patients with mental illness is not new, as early asylum care depicts patients chained to walls and denied clothing (Reference BelkinBelkin, 2002). Although care in Irish psychiatric hospitals is far removed from this, many open acute psychiatric in-patient units maintain a policy of placing newly admitted patients, both voluntary and involuntary, in night attire and withholding their day clothes, apparently for the purposes of reducing absconding and self-harm.
Insistence on night clothes is perceived by some patients as a means of controlling and restricting their freedom (Reference Wallace, Robertson and MillarWallace et al, 1999). It may contribute to institutional neurosis (Reference BartonBarton, 1959) and is arguably contrary to Articles 1, 5 and 9 of the Universal Declaration of Human Rights (United Nations, 1973) and Article 3 of the European Convention on Human Rights (Council of Europe, 1950). More recently, Article 9.1 of the Council of Europe Committee of Ministers recommendations to member states concerning the protection of the human rights and dignity of persons with mental disorder (Council of Europe, 2004), states that the environment and living conditions of persons with a mental disorder should be equitable, in so far as is possible, with those of persons with similar age, gender and culture in the community, a recommendation which is not fully adhered to by the use of night attire in this context. The diagnostic inquiry on the human rights of persons with mental disorders in Central America considered that keeping patients in pyjamas violated their right to quality of life (Reference Levav and González UzcátequiLevav & González Uzcátequi, 2000). The use of night attire to prevent absconding is neither supported by literature reviews (Reference Bowers, Jarrett and ClarkBowers et al, 1998), nor part of recently implemented anti-absconding interventions (Reference Bowers, Alexander and GaskellBowers et al, 2003; Reference Bowers, Simpson and AlexanderBowers et al, 2005).
Gray & Higenbottam (Reference Gray and Higenbottam1982) reported widespread placement of patients in pyjamas despite their being ambulatory and not acutely ill, in order to facilitate physical examinations and manage rule infractions. They recommended that the efficacy of this practice requires demonstration in light of associated dehumanisation, 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 patients in night attire, its clinical and demographic associations, and the attitudes of patients and nursing staff towards it.
Method
We used a triangulation design incorporating data from medical case notes, questionnaires completed by nursing staff and interviews with in-patients in an open acute psychiatric ward in a local general hospital in Ireland.
We reviewed medical and nursing notes relating to all admissions over 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 of the patient in night attire, whether this was requested in writing, and whether reasons were documented for making this request.
An anonymous questionnaire was posted to all 35 members of nursing staff working in the unit to ascertain their attitudes towards placement of patients in night clothes. Thirty-five in-patients who had made the transition from night attire to day clothes were also interviewed to assess their attitudes. The patient questionnaire confirmed that they were asked to hand in day clothes on admission, their reactions to this and their beliefs regarding the right to choose their clothes. (Copies of the questionnaire available from the authors.)
Ethical approval for the study was granted by the Galway University Hospitals Clinical Research Ethics Committee. Data was analysed using SPSS version 12 for Windows, with χ2 analysis for clinical associations of nominal variables.
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 sample was 44.4 years (s.d.=14.7). The mean length of stay was 25.4 days (s.d.=34.7).
The ICD–10 diagnoses of all patients were recorded on discharge: 42.7% patients had moderate depression, 13% had manic bipolar disorder, 13% paranoid schizophrenia, 9.2% depressed schizoaffective disorder, 4.9% alcohol dependence, and other ICD–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 mental health nurses, 6.5% by general hospital wards, 4.3% by accident and emergency, and 1.6% by police.
As many as 106 patients (57.3%) were placed in night attire at the time of admission, a process recommended by doctors in 59 case notes (55.7%), although only 3 case notes (2.8%) contained a documented reason for doing so. The mean proportion of 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 association between being admitted involuntarily and being placed in night attire (χ2=7.58, d.f.=1, P=0.006), but no significant association with gender or a diagnosis of psychotic v. non-psychotic illness.
Clinical associations of placement in night attire
| Patient legal status n (%) | Gender n (%) | Diagnosis n (%) | ||||
|---|---|---|---|---|---|---|
| Placement in night attire | Voluntary | Involuntary | Male | Female | Non-psychotic | Psychotic |
| No | 72 (47.4) | 7 (21.2) | 49 (49.0) | 30 (35.3) | 44 (44.0) | 35 (41.2) |
| Yes | 80 (52.6) | 26 (78.8) | 51 (51.0) | 55 (64.7) | 56 (56.0) | 50 (58.8) |
| χ2 (d.f.) | 7.58 (1)** | 3.53 (1)* | 0.15 (1)* | |||
Survey of nursing staff
Completed questionnaires were returned by 27 staff (a response rate of 77%), of which 81.5% were staff nurses and the rest nurse managers. The majority of respondents were women (n=19, 70.4%). The mean age was 35.7 years (s.d.=9.9) and the mean length of service was 14.3 years (s.d.=9.4).
The perceived reasons by nursing staff for placing patients in night clothes are outlined in Box 1; most of them thought that this would help reduce the risk of absconding or self-harm.
The majority of staff (77.8%) believed that night attire was effective in addressing their chosen reasons. However, 48.1% of nursing staff described the practice as detrimental through loss of independence, enforcement of the sick-role, loss of dignity, 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 choice too. Nursing staff commented that night attire was ‘useful for determining a patient's willingness to remain in the unit,’ and that it ‘allowed time for staff to assess a newly referred patient and to evaluate whether the patient was at risk of absconding’.
Box 1. Reasons identified by nursing staff for placing patients in night attire
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• To reduce the risk of deliberate self harm, 16 (59.3%)
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• To deprive the patient of privilege, 2 (7.4%)
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• To reduce the risk of a patient absconding from the ward, 24 (88.9%)
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• Other, 8 (29.6%)1
1. ‘Other’reasons included: ‘hospital policy’, ‘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; mean age 38.7 years (s.d.=10.0). More than half of the interviewed patients (68.6%) reported feeling uncomfortable in night attire during the daytime. Reasons given included embarrassment and humiliation, lack of privacy, futility of the process, restricted ability to move around the ward, awkwardness, punitive associations and being easily identified as a psychiatric patient. A significant majority (80%) believed that they should retain the right to choose their clothes, 11.4% thought that they should not be given 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 the purpose, it wouldn't stop me leaving if I really wanted to,’ ‘I have no privacy in pyjamas, it is quite humiliating really,’ although another patient felt that ‘I don't mind it really, it helps me to rest’.
Discussion
This study demonstrates a high prevalence of the use of night attire in an in-patient unit, with medical documentation for this practice rarely provided. Absconding is a significant concern and is linked to risk of harm to self and others (Reference CrammerCrammer, 1984; Reference SheppardSheppard, 1996). Patients abscond for several reasons, including feeling bored, frightened, trapped, confined and isolated from family/friends (Reference Bowers, Jarrett and ClarkBowers et al, 1999). Studies investigating efficacy of reduced ‘restrictive’ care practices and subsequent absconding rates report conflicting results (Reference CancroCancro, 1968; Reference Gudeman, Dickey and EvansGudeman et al, 1985; Reference Molnar, Keitner and SwindallMolnar et al, 1985), although a recent implementation of an anti-absconding package demonstrated reduced absconding rates (Reference Bowers, Alexander and GaskellBowers et al, 2003; Reference Bowers, Simpson and AlexanderBowers et al, 2005). Elements of this package included a sign-in book for patients, supportive breaking of bad news, debriefing of patients regarding ward incidents, multidisciplinary review, identification of patients at high risk of absconding, targeted nursing time daily for those patients and facilitation of social contact. Placing patients in night attire is not documented as an effective part of any anti-absconding package, and may represent a form of conflict-generating preventive containment (Reference BowersBowers, 2006).
In-patient prevention of self-harm has traditionally involved maintenance of physical safety, although the use of no-harm contracts with patients and a one-to-one observation of a patient by a nurse have not had a significant impact here (Reference DrewDrew, 2001; Reference Potter and DawsonPotter & Dawson, 2001). Data from an Irish qualitative descriptive study investigating the intervention and prevention strategies used by eight psychiatric nurses when working with non-suicidal self-harming in-patients revealed that the practice of placing patients in their night clothes is followed in order to attempt to ensure safety, although the staff remained unsure of the rationale or efficacy associated with this intervention (Reference O'DonovanO’Donovan, 2007). The National Institute for Health and Clinical Excellence guidelines recommend involvement of people 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's autonomy is associated with self-reported improvement in mental health (Reference Kjellin, Andersson and CandefjordKjellin et al, 1997; Reference O'Brien and GoldingO’Brien & Golding, 2003).
Our findings reveal conflicting views of nursing staff and patients regarding the effects of having to wear night clothes at daytime and the rights of patients to choose their daytime attire. The recently implemented Irish Mental Health Act 2001 states that ‘due regard shall be given to the need to respect the right of the person to dignity, bodily integrity, privacy and autonomy’ (Office of the Attorney General, 2001), implying that involuntary admission is not synonymous with complete surrender of rights. Furthermore, removal of day clothes from voluntary patients could be considered an insidious form of detention which breaches current mental health legislation.
Strengths of this study include the triangulation design which combined qualitative and quantitative data from a large complete sample of written case notes, a high response rate to questionnaires from nursing staff, and participation by a representative sample of patients. However, these findings may not generalise to closed wards, where different attitudes and usage of interventions may exist.
These findings demonstrate that night attire is used for a substantial proportion of in-patients despite the lack of evidence to support its usefulness as a therapeutic intervention to protect against absconding or self-harm. Its use may fuel conflict between staff members and patients given the apparently disparate attitudes towards its use by the two groups. Staff should consider alternative mechanisms in order to manage risk in a manner that would be more acceptable to patients and more respectful of their dignity and autonomy. We suggest that, when psychiatrists recommend that patients be placed in night attire, due attention should be given to the fact that some patients may perceive this as undermining their autonomy and the decision and reasons for it should be documented in the medical notes.
Declaration of interest
None.
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