The effect of staffing levels on the use of seclusion

Deprivation of Liberty in Psychiatric Treatment: a Finnish perspective

This article is concerned with the deprivation of patients’ liberty while undergoing psychiatric treatment, with special reference to the situation in Finland. It is based on a review of Finnish law, health care statistics, and empirical and theoretical studies. Relevant research findings from other countries are also discussed. In Finland, it is required that patients are cared for by mutual understanding with themselves; coercive measures may be applied only if they are necessary for the treatment of the illness, or for safeguarding patients’ safety or the safety of others. Involuntary psychiatric hospitalization is closely regulated by the Mental Health Act. However, the rules concerning the deprivation of liberty during inpatient treatment (by seclusion, restraint and restricted leave) are formulated in very general terms. Therefore, Finnish psychiatric hospitals have their own policies concerning when and how seclusion may be used. The practice of seclusion and the use of restraint therefore vary among the psychiatric hospitals in Finland.

Seclusion and the importance of contextual factors: An innovation project revisited

Variation in seclusion rates between psychiatric facilities cannot be adequately explained by patient characteristics alone and there is a growing awareness of the influence of 'cultural' and staff factors on the use of seclusion. In this study, staff variables as well as seclusion parameters were investigated during the implementation of an innovation project, against the background of an institutional program to reduce the use of coercive measures. The results demonstrate the impact of confidence within the team, staffing level and communication with the patient on nurses' decisions on seclusion. The importance of the organizational context is further illustrated by the negative effects of organizational instability on nurses' attitudes and decision making with respect to seclusion, and on seclusion rates. A reduction in the use of seclusion was achieved after the implementation of the innovation project; however, during a period of organizational turmoil, the work engagement scores of staff decreased and the use of seclusion increased. The results of this study show the vulnerability of innovations within the continuously changing organizational context of mental health care.

Reducing seclusion through involuntary medication: a randomized clinical trial

The study evaluated whether seclusion and coercive incidents would be reduced in extent and number if involuntary medication was the first choice of intervention. Patients admitted to an acute psychiatric ward were randomly allocated to two groups. In Group 1, involuntary medication was the intervention of first choice for dealing with agitation and risk of violence. In Group 2, seclusion was the intervention of first choice. Patients' characteristics between the groups were compared by Pearson χ(2) and two-sample t-tests; the incidence rates and risk ratios (RRs) were calculated to examine differences in number and duration of coercive incidents. In Group 1, the relative risk of being secluded was lower than in Group 2, whereas the risk of receiving involuntary medication was higher. However, the mean duration of the seclusion incidents did not differ significantly between the two groups; neither did the total number of coercive incidents. Although the use of involuntary medication could successfully replace and reduce the number of seclusions, alternative interventions are needed to reduce the overall number and duration of coercive incidents. A new policy for managing acute aggression - such as involuntary medication - can be implemented effectively only if certain conditions are met.

Early detection of risk factors for seclusion and restraint: a prospective study

AIM

The study aims to examine the predictive power of static and dynamic risk factors assessed at admission to an acute psychiatric ward and to develop a prediction model evaluating the risk of seclusion and restraint.

METHODS

Over 20 months, data on demographic and clinical characteristics, psychosocial functioning, level of insight, uncooperativeness, and use of coercive measures were collected prospectively on 520 patients at admission. Logistic regression analysis was used to develop a prediction model. The magnitude of the predictive power of this model was estimated using receiver operating characteristic analysis.

RESULTS

The prediction model contained one static predictor (involuntary commitment) and two dynamic predictors (psychological impairment and uncooperativeness), with a high predictive power (receiver operating characteristic area under the curve = 0.83). The final risk model classified 72% of the patients correctly, with a higher sensitivity rate (80%) than specificity rate (71%).

CONCLUSION

Early assessment of patients' psychological impairment and uncooperativeness can help clinicians to recognize patients at risk for coercive measures and approach them on time with preventive and less restrictive interventions. Although this simple, highly predictive model accurately predicts the risk of seclusion or restraint, further validation studies are needed before it can be adopted into routine clinical practice.

Nurses' decision on seclusion: patient characteristics, contextual factors and reflexivity in teams

While many characteristics of patients, professionals and facilities with relevance to seclusion rates have been investigated, their relative importance is unclear. Virtually no attention has been paid to team processes and reflexivity in relation to decision making on seclusion. The aim of this paper is to estimate the effects of these factors on nurse decision making on seclusion. Sixty Dutch psychiatric nurses of four closed wards reported team reflexivity and their tendency to seclude a theoretical patient. Approachability (whether there was a good or hardly any possibility to communicate with the patient), staffing level and confidence within the team had the greatest impact on the decision to seclude. Intra class correlation was 0.30. There was a large interaction effect of reflexivity with team 4, and team reflexivity was highly correlated with team tendency to avoid seclusion. In nurses' decision on seclusion, the effects of 'pure' patient characteristics are small as compared with the effects of interpersonal and contextual factors, and nurses vary widely in their judgement. Team reflexivity is related to the tendency to prevent seclusion.