EMILIA LAUKKANEN
Coercive measures in Finnish psychiatric inpatient care – special emphasis on psychiatric nursing managers’ attitudes
Dissertations in Health Sciences
PUBLICATIONS OF
THE UNIVERSITY OF EASTERN FINLAND
COERCIVE MEASURES IN FINNISH PSYCHIATRIC
INPATIENT CARE – SPECIAL EMPHASIS ON
PSYCHIATRIC NURSING MANAGERS’ ATTITUDES
Emilia Laukkanen
COERCIVE MEASURES IN FINNISH PSYCHIATRIC INPATIENT CARE – SPECIAL EMPHASIS ON PSYCHIATRIC NURSING MANAGERS’ ATTITUDES
To be presented by permission of the Faculty of Health Sciences,
University of Eastern Finland for public examination in MS300 Auditorium, Kuopio on January 29th, 2021, at 12 o’clock noon
Publications of the University of Eastern Finland Dissertations in Health Sciences
No 608
Department of Nursing Science and Department of Forensic Psychiatry University of Eastern Finland, Kuopio
2021
Emilia Laukkanen
COERCIVE MEASURES IN FINNISH PSYCHIATRIC INPATIENT CARE – SPECIAL EMPHASIS ON PSYCHIATRIC NURSING MANAGERS’ ATTITUDES
To be presented by permission of the Faculty of Health Sciences,
University of Eastern Finland for public examination in MS300 Auditorium, Kuopio on January 29th, 2021, at 12 o’clock noon
Publications of the University of Eastern Finland Dissertations in Health Sciences
No 608
Department of Nursing Science and Department of Forensic Psychiatry University of Eastern Finland, Kuopio
2021
Series Editors
Professor Tomi Laitinen, M.D., Ph.D.
Institute of Clinical Medicine, Clinical Physiology and Nuclear Medicine Faculty of Health Sciences
Professor Tarja Kvist, Ph.D.
Department of Nursing Science Faculty of Health Sciences Professor Ville Leinonen, M.D., Ph.D.
Institute of Clinical Medicine, Neurosurgery Faculty of Health Sciences
Professor Tarja Malm, Ph.D.
A.I. Virtanen Institute for Molecular Sciences Faculty of Health Sciences
Lecturer Veli-Pekka Ranta, Ph.D.
School of Pharmacy Faculty of Health Sciences
Distributor:
University of Eastern Finland Kuopio Campus Library
P.O.Box 1627 FI-70211 Kuopio, Finland
www.uef.fi/kirjasto Grano Oy Kuopio, 2021
ISBN: 978-952-61-3700-1 (print/nid.) ISBN: 978-952-61-3701-8 (PDF)
ISSNL: 1798-5706 ISSN: 1798-5706 ISSN: 1798-5714 (PDF)
Author’s address: Department of Nursing Science University of Eastern Finland KUOPIO
FINLAND
Doctoral programme: Doctoral Program of Health Sciences Supervisors: Professor Katri Vehviläinen-Julkunen, Ph.D.
Department of Nursing Science University of Eastern Finland KUOPIO
FINLAND
University Lecturer Lauri Kuosmanen, Ph.D. Department of Nursing Science
University of Eastern Finland KUOPIO
FINLAND
Reviewers: Professor Eimear Muir-Cochrane, Ph.D.
College of Nursing and Health Sciences Flinders University
ADELAIDE, SOUTH AUSTRALIA AUSTRALIA
Professor Michelle Cleary, Ph.D. College of Health and Medicine University of Tasmania
SYDNEY, NEW SOUTH WALES AUSTRALIA
Opponent: Adjunct Professor Raija Kontio, Ph.D.
Department of Nursing Science University of Turku
TURKU FINLAND
Series Editors
Professor Tomi Laitinen, M.D., Ph.D.
Institute of Clinical Medicine, Clinical Physiology and Nuclear Medicine Faculty of Health Sciences
Professor Tarja Kvist, Ph.D.
Department of Nursing Science Faculty of Health Sciences Professor Ville Leinonen, M.D., Ph.D.
Institute of Clinical Medicine, Neurosurgery Faculty of Health Sciences
Professor Tarja Malm, Ph.D.
A.I. Virtanen Institute for Molecular Sciences Faculty of Health Sciences
Lecturer Veli-Pekka Ranta, Ph.D.
School of Pharmacy Faculty of Health Sciences
Distributor:
University of Eastern Finland Kuopio Campus Library
P.O.Box 1627 FI-70211 Kuopio, Finland
www.uef.fi/kirjasto Grano Oy Kuopio, 2021
ISBN: 978-952-61-3700-1 (print/nid.) ISBN: 978-952-61-3701-8 (PDF)
ISSNL: 1798-5706 ISSN: 1798-5706 ISSN: 1798-5714 (PDF)
Author’s address: Department of Nursing Science University of Eastern Finland KUOPIO
FINLAND
Doctoral programme: Doctoral Program of Health Sciences Supervisors: Professor Katri Vehviläinen-Julkunen, Ph.D.
Department of Nursing Science University of Eastern Finland KUOPIO
FINLAND
University Lecturer Lauri Kuosmanen, Ph.D.
Department of Nursing Science University of Eastern Finland KUOPIO
FINLAND
Reviewers: Professor Eimear Muir-Cochrane, Ph.D.
College of Nursing and Health Sciences Flinders University
ADELAIDE, SOUTH AUSTRALIA AUSTRALIA
Professor Michelle Cleary, Ph.D.
College of Health and Medicine University of Tasmania
SYDNEY, NEW SOUTH WALES AUSTRALIA
Opponent: Adjunct Professor Raija Kontio, Ph.D.
Department of Nursing Science University of Turku
TURKU FINLAND
Laukkanen, Emilia
Coercive measures in Finnish psychiatric inpatient care – special emphasis on psychiatric nursing managers’ attitudes
Kuopio: University of Eastern Finland
Publications of the University of Eastern Finland Dissertations in Health Sciences 608. 2021, 110 p.
ISBN: 978-952-61-3700-1 (print) ISSNL: 1798-5706
ISSN: 1798-5706
ISBN: 978-952-61-3701-8 (PDF) ISSN: 1798-5714 (PDF)
ABSTRACT
This thesis aims to review nursing staff attitudes towards coercive measures, examine the incidences of seclusion, mechanical restraint, physical restraint, and involuntary medication in Finnish specialized psychiatric care during a one-year period, investigate psychiatric nursing managers’ attitudes towards coercive measures, and analyze the associations between attitudes towards coercive measures and the use of these practices.
The research underlying this thesis was retrospective, with the data collection methods including integrative literature review, register study, and questionnaire survey. The literature review data concerning nursing staff attitudes towards coercive measures were collected from empirical studies published between 2002 and 2018. The ward-level register data concerning the year 2017 were collected from all Finnish specialized care organizations (n=22), which comprise 140 psychiatric wards within hospital districts and government psychiatric hospitals. The questionnaire concerning attitudes towards coercive measures, which utilized the Attitudes to Containment Measures Questionnaire, was sent to all specialized psychiatric inpatient care nursing managers, of which 90 responded to the questionnaire. The associations between attitudes and coercive measures were investigated among managers (n=70) of wards that applied coercive measures. Parametric methods and naïve Bayesian modelling were utilized in the statistical analysis of collected data. This thesis draws upon the results of four articles published in peer-reviewed international journals.
The research presented in this thesis revealed that nursing staff attitudes towards coercive measures have recently become more negative, but the use of coercive measures is still often perceived as necessary. For example, during 2017, seclusion was applied 4006 times, mechanical restraint was used 2113 times, physical restraint was
Laukkanen, Emilia
Coercive measures in Finnish psychiatric inpatient care – special emphasis on psychiatric nursing managers’ attitudes
Kuopio: University of Eastern Finland
Publications of the University of Eastern Finland Dissertations in Health Sciences 608. 2021, 110 p.
ISBN: 978-952-61-3700-1 (print) ISSNL: 1798-5706
ISSN: 1798-5706
ISBN: 978-952-61-3701-8 (PDF) ISSN: 1798-5714 (PDF)
ABSTRACT
This thesis aims to review nursing staff attitudes towards coercive measures, examine the incidences of seclusion, mechanical restraint, physical restraint, and involuntary medication in Finnish specialized psychiatric care during a one-year period, investigate psychiatric nursing managers’ attitudes towards coercive measures, and analyze the associations between attitudes towards coercive measures and the use of these practices.
The research underlying this thesis was retrospective, with the data collection methods including integrative literature review, register study, and questionnaire survey. The literature review data concerning nursing staff attitudes towards coercive measures were collected from empirical studies published between 2002 and 2018. The ward-level register data concerning the year 2017 were collected from all Finnish specialized care organizations (n=22), which comprise 140 psychiatric wards within hospital districts and government psychiatric hospitals. The questionnaire concerning attitudes towards coercive measures, which utilized the Attitudes to Containment Measures Questionnaire, was sent to all specialized psychiatric inpatient care nursing managers, of which 90 responded to the questionnaire. The associations between attitudes and coercive measures were investigated among managers (n=70) of wards that applied coercive measures. Parametric methods and naïve Bayesian modelling were utilized in the statistical analysis of collected data. This thesis draws upon the results of four articles published in peer-reviewed international journals.
The research presented in this thesis revealed that nursing staff attitudes towards coercive measures have recently become more negative, but the use of coercive measures is still often perceived as necessary. For example, during 2017, seclusion was applied 4006 times, mechanical restraint was used 2113 times, physical restraint was
applied 1064 times, and involuntary medication was used 2187 times. The extent to which coercive measures were applied fluctuated between wards. Nursing managers’
attitudes towards coercive measures also varied, and it is important to note that the managers were generally less accepting of these practices than clinical nursing staff.
Associations between attitudes and seclusion, mechanical restraint, and physical restraint were discovered. Nursing managers’ positive attitudes towards more restrictive measures were associated to a heavier use of coercive measures, and positive attitudes towards less restrictive measures was associated to decreased use of coercive measures.
The research presented in this thesis provides new information that can be used to hopefully reduce the incidence of coercive measures in the future. The research highlights that we should pay more attention to the attitudes of nursing staff and managers, and that the use of coercive measures should be further mapped and surveyed at the ward level. The knowledge base underlying this thesis also reveals a need for more accurate information about the associations between attitudes and coercive measures. In addition, investigations focusing on how other variables, e.g., patient, staff, and organizational characteristics, are associated with the use of coercive measures should be conducted.
Keywords: Hospitals, Psychiatric; Psychiatric Nursing; Coercion; Attitude of Health Personnel; Nursing Managers; Leadership
Laukkanen, Emilia
Pakkotoimet psykiatrisessa sairaalahoidossa – keskiössä hoitotyön johtajien asenteet Kuopio: Itä-Suomen yliopisto
Publications of the University of Eastern Finland Dissertations in Health Sciences 608. 2021, 110 s.
ISBN: 978-952-61-3700-1 (nid.) ISSNL: 1798-5706
ISSN: 1798-5706
ISBN: 978-952-61-3701-8 (PDF) ISSN: 1798-5714 (PDF)
TIIVISTELMÄ
Tämän tutkimuksen tarkoituksena oli kartoittaa hoitotyöntekijöiden asenteita pakkotoimia kohtaan, selvittää kuinka paljon eristämistä, sitomista, kiinnipitoa ja tahdonvastaista lääkitystä käytettiin suomalaisessa psykiatrisessa
erikoissairaanhoidossa yhden vuoden aikana, tutkia psykiatrisen hoitotyön johtajien asenteita pakkotoimien käyttöä kohtaan ja analysoida johtajien asenteiden yhteyttä pakkotoimien käyttöön.
Tutkimusasetelma oli retrospektiivinen. Aineistonkeruumenetelminä käytettiin integratiivista kirjallisuuskatsausta, rekisteritutkimusta ja kyselytutkimusta.
Kirjallisuuskatsauksen aineisto kerättiin vuosina 2002–2018 julkaistuista empiirisistä tutkimuksista, jotka käsittelivät hoitotyöntekijöiden asenteita pakkotoimia kohtaan.
Osastokohtainen rekisteriaineisto kerättiin kaikista suomalaisista erikoissairaanhoidon organisaatioista (n=22) vuoden 2017 osalta, yhteensä 140 psykiatriselta osastolta, sekä sairaanhoitopiireistä että valtion sairaaloista. Kysely, jossa kartoitettiin asenteita potilaan rajoittamiskeinoja kohtaan Attitudes to Containment Methods Questionnaire - mittarilla, lähetettiin kaikille psykiatrisen erikoissairaanhoidon osastohoidon hoitotyön johtajille, joista 90 vastasi kyselyyn. Asenteiden ja pakkotoimien yhteyttä tutkittiin niiden johtajien (n=70) osalta, jotka olivat johtajina pakkotoimia käyttäneillä osastoilla.
Tilastollisissa analyyseissa hyödynnettiin parametrisia menetelmiä ja naiivia Bayesin mallinnusta. Tutkimuksen tulokset julkaistiin neljässä kansainvälisessä,
vertaisarvioidussa julkaisussa, sekä väitöskirjan yhteenveto-osassa.
Tutkimus osoitti, että hoitotyöntekijöiden asenteet pakkotoimia kohtaan ovat muuttuneet aiempaa negatiivisemmiksi, mutta pakkotoimien käyttö koetaan silti usein tarpeellisena. Eristämistä käytettiin Suomessa vuonna 2017 yhteensä 4006 kertaa, sitomista 2113 kertaa, kiinnipitoa 1064 kertaa ja tahdonvastaista lääkitystä 2187 kertaa.
Eri osastojen välillä oli vaihtelua pakkotoimien määrässä. Hoitotyön johtajien asenteet
applied 1064 times, and involuntary medication was used 2187 times. The extent to which coercive measures were applied fluctuated between wards. Nursing managers’
attitudes towards coercive measures also varied, and it is important to note that the managers were generally less accepting of these practices than clinical nursing staff.
Associations between attitudes and seclusion, mechanical restraint, and physical restraint were discovered. Nursing managers’ positive attitudes towards more restrictive measures were associated to a heavier use of coercive measures, and positive attitudes towards less restrictive measures was associated to decreased use of coercive measures.
The research presented in this thesis provides new information that can be used to hopefully reduce the incidence of coercive measures in the future. The research highlights that we should pay more attention to the attitudes of nursing staff and managers, and that the use of coercive measures should be further mapped and surveyed at the ward level. The knowledge base underlying this thesis also reveals a need for more accurate information about the associations between attitudes and coercive measures. In addition, investigations focusing on how other variables, e.g., patient, staff, and organizational characteristics, are associated with the use of coercive measures should be conducted.
Keywords: Hospitals, Psychiatric; Psychiatric Nursing; Coercion; Attitude of Health Personnel; Nursing Managers; Leadership
Laukkanen, Emilia
Pakkotoimet psykiatrisessa sairaalahoidossa – keskiössä hoitotyön johtajien asenteet Kuopio: Itä-Suomen yliopisto
Publications of the University of Eastern Finland Dissertations in Health Sciences 608. 2021, 110 s.
ISBN: 978-952-61-3700-1 (nid.) ISSNL: 1798-5706
ISSN: 1798-5706
ISBN: 978-952-61-3701-8 (PDF) ISSN: 1798-5714 (PDF)
TIIVISTELMÄ
Tämän tutkimuksen tarkoituksena oli kartoittaa hoitotyöntekijöiden asenteita pakkotoimia kohtaan, selvittää kuinka paljon eristämistä, sitomista, kiinnipitoa ja tahdonvastaista lääkitystä käytettiin suomalaisessa psykiatrisessa
erikoissairaanhoidossa yhden vuoden aikana, tutkia psykiatrisen hoitotyön johtajien asenteita pakkotoimien käyttöä kohtaan ja analysoida johtajien asenteiden yhteyttä pakkotoimien käyttöön.
Tutkimusasetelma oli retrospektiivinen. Aineistonkeruumenetelminä käytettiin integratiivista kirjallisuuskatsausta, rekisteritutkimusta ja kyselytutkimusta.
Kirjallisuuskatsauksen aineisto kerättiin vuosina 2002–2018 julkaistuista empiirisistä tutkimuksista, jotka käsittelivät hoitotyöntekijöiden asenteita pakkotoimia kohtaan.
Osastokohtainen rekisteriaineisto kerättiin kaikista suomalaisista erikoissairaanhoidon organisaatioista (n=22) vuoden 2017 osalta, yhteensä 140 psykiatriselta osastolta, sekä sairaanhoitopiireistä että valtion sairaaloista. Kysely, jossa kartoitettiin asenteita potilaan rajoittamiskeinoja kohtaan Attitudes to Containment Methods Questionnaire - mittarilla, lähetettiin kaikille psykiatrisen erikoissairaanhoidon osastohoidon hoitotyön johtajille, joista 90 vastasi kyselyyn. Asenteiden ja pakkotoimien yhteyttä tutkittiin niiden johtajien (n=70) osalta, jotka olivat johtajina pakkotoimia käyttäneillä osastoilla.
Tilastollisissa analyyseissa hyödynnettiin parametrisia menetelmiä ja naiivia Bayesin mallinnusta. Tutkimuksen tulokset julkaistiin neljässä kansainvälisessä,
vertaisarvioidussa julkaisussa, sekä väitöskirjan yhteenveto-osassa.
Tutkimus osoitti, että hoitotyöntekijöiden asenteet pakkotoimia kohtaan ovat muuttuneet aiempaa negatiivisemmiksi, mutta pakkotoimien käyttö koetaan silti usein tarpeellisena. Eristämistä käytettiin Suomessa vuonna 2017 yhteensä 4006 kertaa, sitomista 2113 kertaa, kiinnipitoa 1064 kertaa ja tahdonvastaista lääkitystä 2187 kertaa.
Eri osastojen välillä oli vaihtelua pakkotoimien määrässä. Hoitotyön johtajien asenteet
pakkotoimien käyttöä kohtaan vaihtelivat, vaikka asenteet olivat pääsääntöisesti negatiivisempia kuin käytännön hoitotyötä tekevien. Johtajien asenteilla oli yhteys eristämisen, sitomisen ja kiinnipidon käyttöön. Hoitotyön johtajien positiiviset asenteet rajoittavampia menetelmiä kohtaan olivat yhteydessä suurempaan pakkotoimien käyttöön, ja positiiviset asenteet vähemmän rajoittavia menetelmiä kohtaan olivat yhteydessä vähäisempään pakkotoimien käyttöön.
Tämä tutkimus tuottaa tietoa, jota voidaan hyödyntää tulevaisuudessa pakkotoimien vähentämisessä. Hoitotyöntekijöiden ja johtajien asenteisiin tulisi kiinnittää aiempaa enemmän huomiota, ja pakkotoimien käyttöä tulisi edelleen kartoittaa ja tutkia osastotasolla. Myös muiden potilaaseen, henkilökuntaan ja organisaatioon liittyvien tekijöiden yhteyttä pakkotoimien käyttöön tulisi tutkia laajojen rekisteriaineistojen avulla.
Avainsanat: psykiatrinen hoito; pakkotoimet; asenteet; hoitotyö; johtajat
ACKNOWLEDGEMENTS
This study was conducted at the University of Eastern Finland, at the Department of Nursing Science, Faculty of Health Sciences, in collaboration with the Department of Forensic Psychiatry. I wish to express my gratitude to the University of Eastern Finland and the Faculty of Health Sciences for making this project possible.
I would like to express my sincerest gratitude to my supervisors, Professor, Ph.D.
Katri Vehviläinen-Julkunen, and University Lecturer, Ph.D. Lauri Kuosmanen. Katri, you guided and supported me gently through this process and kindly offered to share your valuable expertise. Lauri, I would like to thank you for your positive attitude and for supporting and inspiring me since the day I began to plan this study.
I am grateful to the pre-examiners, Professor Michelle Cleary and Professor Eimear Muir-Cochrane for thoroughly reviewing this thesis and for encouraging me to continue doing research in the future.
I also owe my gratitude to my co-authors, Ph.D. Olavi Louheranta, Dr. Med. Sci, Professor Emeritus Olli-Pekka Ryynänen, and MSc, Biostatistician Tuomas Selander.
Also, I would like to thank all the study participants and the people who helped me during the research permission application and the data collection processes. This study would not have been possible without your valuable help.
I would like to thank several instances for the financial support during this project:
Finnish Cultural Foundation, North Savo Regional Fund; Niuvanniemi hospital;
University of Eastern Finland, Faculty of Health Sciences; Akavan Sairaanhoitajat ja Taja ry; The Finnish Nursing Education Foundation sr; Savon Sairaanhoitajat ry; and
Mielenterveystyön kehittäminen ja tutkimus ry. I would also like to thank the Finnish
“Verkosto pakon käytön vähentämiseksi” network for collaboration and for all the efforts aiming to reduce coercive measures in Finland.
I would like to thank all my colleagues in Niuvanniemi hospital, Municipality of Siilinjärvi, and Finnish Medicines Agency Fimea for your support. I would especially like to express my gratitude to former Chief Director of Nursing Osmo Vuorio, Chief Director of Nursing Aila Vokkolainen, Director of Nursing Irkku Höök, and Director of Nursing Satu Tuovinen from Niuvanniemi hospital for supporting me in the early stages of my career as a researcher and as a nursing manager. I would also like to thank secretary Aija Räsänen and research secretary Tarja Koskela from Niuvanniemi hospital for your valuable help during the entire process. In addition, I am grateful to Director Pertti Happonen and Head of Research and Development Katri Hämeen-Anttila from Finnish Medicines Agency Fimea for believing in me.
pakkotoimien käyttöä kohtaan vaihtelivat, vaikka asenteet olivat pääsääntöisesti negatiivisempia kuin käytännön hoitotyötä tekevien. Johtajien asenteilla oli yhteys eristämisen, sitomisen ja kiinnipidon käyttöön. Hoitotyön johtajien positiiviset asenteet rajoittavampia menetelmiä kohtaan olivat yhteydessä suurempaan pakkotoimien käyttöön, ja positiiviset asenteet vähemmän rajoittavia menetelmiä kohtaan olivat yhteydessä vähäisempään pakkotoimien käyttöön.
Tämä tutkimus tuottaa tietoa, jota voidaan hyödyntää tulevaisuudessa pakkotoimien vähentämisessä. Hoitotyöntekijöiden ja johtajien asenteisiin tulisi kiinnittää aiempaa enemmän huomiota, ja pakkotoimien käyttöä tulisi edelleen kartoittaa ja tutkia osastotasolla. Myös muiden potilaaseen, henkilökuntaan ja organisaatioon liittyvien tekijöiden yhteyttä pakkotoimien käyttöön tulisi tutkia laajojen rekisteriaineistojen avulla.
Avainsanat: psykiatrinen hoito; pakkotoimet; asenteet; hoitotyö; johtajat
ACKNOWLEDGEMENTS
This study was conducted at the University of Eastern Finland, at the Department of Nursing Science, Faculty of Health Sciences, in collaboration with the Department of Forensic Psychiatry. I wish to express my gratitude to the University of Eastern Finland and the Faculty of Health Sciences for making this project possible.
I would like to express my sincerest gratitude to my supervisors, Professor, Ph.D.
Katri Vehviläinen-Julkunen, and University Lecturer, Ph.D. Lauri Kuosmanen. Katri, you guided and supported me gently through this process and kindly offered to share your valuable expertise. Lauri, I would like to thank you for your positive attitude and for supporting and inspiring me since the day I began to plan this study.
I am grateful to the pre-examiners, Professor Michelle Cleary and Professor Eimear Muir-Cochrane for thoroughly reviewing this thesis and for encouraging me to continue doing research in the future.
I also owe my gratitude to my co-authors, Ph.D. Olavi Louheranta, Dr. Med. Sci, Professor Emeritus Olli-Pekka Ryynänen, and MSc, Biostatistician Tuomas Selander.
Also, I would like to thank all the study participants and the people who helped me during the research permission application and the data collection processes. This study would not have been possible without your valuable help.
I would like to thank several instances for the financial support during this project:
Finnish Cultural Foundation, North Savo Regional Fund; Niuvanniemi hospital;
University of Eastern Finland, Faculty of Health Sciences; Akavan Sairaanhoitajat ja Taja ry; The Finnish Nursing Education Foundation sr; Savon Sairaanhoitajat ry; and
Mielenterveystyön kehittäminen ja tutkimus ry. I would also like to thank the Finnish
“Verkosto pakon käytön vähentämiseksi” network for collaboration and for all the efforts aiming to reduce coercive measures in Finland.
I would like to thank all my colleagues in Niuvanniemi hospital, Municipality of Siilinjärvi, and Finnish Medicines Agency Fimea for your support. I would especially like to express my gratitude to former Chief Director of Nursing Osmo Vuorio, Chief Director of Nursing Aila Vokkolainen, Director of Nursing Irkku Höök, and Director of Nursing Satu Tuovinen from Niuvanniemi hospital for supporting me in the early stages of my career as a researcher and as a nursing manager. I would also like to thank secretary Aija Räsänen and research secretary Tarja Koskela from Niuvanniemi hospital for your valuable help during the entire process. In addition, I am grateful to Director Pertti Happonen and Head of Research and Development Katri Hämeen-Anttila from Finnish Medicines Agency Fimea for believing in me.
During this process, my friends have supported me in many ways. Asta Halonen, I would like to thank you for helping me in my scientific reflections, but also for listening to my other problems. Jenni Rissanen, I am grateful for your support and our
discussions about science and life in general. Jonna Halinen, I would like to thank you for your overall support during these years and our discussions over a glass of wine.
Janneke van Riel, I am grateful for this friendship that has lasted since the beginning of our nursing careers. I would also like to thank my friends in Mallorca, Riitta and
Esteban, for making it possible for me not to think about this project during my holidays.
I am sincerely grateful to my mother and father, Pirjo and Juha, for your love and support. Throughout my life, you have encouraged me to reach for the stars.
And finally, I would like to thank my cat for reminding me of the most important things in life: eating, sleeping, and relaxation.
Kuopio, 6 December 2020 Emilia Laukkanen
LIST OF ORIGINAL PUBLICATIONS
This dissertation is based on the following original publications:
I Laukkanen E, Vehviläinen-Julkunen K, Louheranta O and Kuosmanen L. Psychiatric nursing staffs’ attitudes towards the use of containment methods in psychiatric inpatient care: An integrative review. International Journal of Mental Health Nursing. 28: 390–406, 2019.
II Laukkanen E, Kuosmanen L, Selander T and Vehviläinen-Julkunen K. Seclusion, restraint, and involuntary medication in Finnish psychiatric care: a register study with root-level data. Nordic Journal of Psychiatry. 74: 439–443, 2020.
III Laukkanen E, Kuosmanen L, Louheranta O and Vehviläinen-Julkunen K. Psychiatric nursing managers' attitudes towards containment methods in psychiatric inpatient care. Journal of Nursing Management. 28: 699–709, 2020.
IV Laukkanen E, Kuosmanen L, Louheranta O, Ryynänen O-P and Vehviläinen- Julkunen K. A Bayesian network model to identify the associations between the use of seclusion in psychiatric care and nursing managers’ attitudes towards containment methods. Submitted.
The publications were adapted with the permission of the copyright owners.
In addition, this summary includes previously unpublished material.
During this process, my friends have supported me in many ways. Asta Halonen, I would like to thank you for helping me in my scientific reflections, but also for listening to my other problems. Jenni Rissanen, I am grateful for your support and our
discussions about science and life in general. Jonna Halinen, I would like to thank you for your overall support during these years and our discussions over a glass of wine.
Janneke van Riel, I am grateful for this friendship that has lasted since the beginning of our nursing careers. I would also like to thank my friends in Mallorca, Riitta and
Esteban, for making it possible for me not to think about this project during my holidays.
I am sincerely grateful to my mother and father, Pirjo and Juha, for your love and support. Throughout my life, you have encouraged me to reach for the stars.
And finally, I would like to thank my cat for reminding me of the most important things in life: eating, sleeping, and relaxation.
Kuopio, 6 December 2020 Emilia Laukkanen
LIST OF ORIGINAL PUBLICATIONS
This dissertation is based on the following original publications:
I Laukkanen E, Vehviläinen-Julkunen K, Louheranta O and Kuosmanen L. Psychiatric nursing staffs’ attitudes towards the use of containment methods in psychiatric inpatient care: An integrative review. International Journal of Mental Health Nursing. 28: 390–406, 2019.
II Laukkanen E, Kuosmanen L, Selander T and Vehviläinen-Julkunen K. Seclusion, restraint, and involuntary medication in Finnish psychiatric care: a register study with root-level data. Nordic Journal of Psychiatry. 74: 439–443, 2020.
III Laukkanen E, Kuosmanen L, Louheranta O and Vehviläinen-Julkunen K. Psychiatric nursing managers' attitudes towards containment methods in psychiatric inpatient care. Journal of Nursing Management. 28: 699–709, 2020.
IV Laukkanen E, Kuosmanen L, Louheranta O, Ryynänen O-P and Vehviläinen- Julkunen K. A Bayesian network model to identify the associations between the use of seclusion in psychiatric care and nursing managers’ attitudes towards containment methods. Submitted.
The publications were adapted with the permission of the copyright owners.
In addition, this summary includes previously unpublished material.
CONTENTS
ABSTRACT ... 7
TIIVISTELMÄ ... 9
ACKNOWLEDGEMENTS ... 11
1 INTRODUCTION ... 21
2 REVIEW OF THE LITERATURE ... 25
2.1 Psychiatric care in Finland ... 25
2.2 Coercive measures ... 26
2.2.1 Definition of coercive measures ... 26
2.2.2 Coercive measures in Finland ... 27
2.2.3 Literature search on the use of coercive measures ... 28
2.2.4 Use of coercive measures ... 30
2.3 Nursing managers’ attitudes ... 32
2.3.1 Nursing management ... 32
2.3.2 Definition of attitude ... 33
2.3.3 The three dimensions of attitudes ... 34
2.3.4 Literature search on nursing managers’ attitudes ... 35
2.3.5 Nursing managers’ attitudes ... 36
2.4 Summary of current theoretical understanding ... 37
3 AIMS OF THE THESIS ... 39
4 METHODS ... 40
4.1 Setting ... 40
4.2 Design ... 40
4.3 Literature review (original study I) ... 40
4.3.1 Aim and method ... 40
4.3.2 Literature search ... 40
4.3.3 Data evaluation... 41
4.3.4 Data analysis ... 41
4.4 Register study (original study II) ... 41
4.4.1 Aim ... 41
4.4.2 Sample and data collection ... 42
4.4.3 Data analysis ... 42
4.5 Survey (original studies III and IV)... 43
4.5.1 Aim ... 43
CONTENTS
ABSTRACT ... 7
TIIVISTELMÄ ... 9
ACKNOWLEDGEMENTS ... 11
1 INTRODUCTION ... 21
2 REVIEW OF THE LITERATURE ... 25
2.1 Psychiatric care in Finland ... 25
2.2 Coercive measures ... 26
2.2.1 Definition of coercive measures ... 26
2.2.2 Coercive measures in Finland ... 27
2.2.3 Literature search on the use of coercive measures ... 28
2.2.4 Use of coercive measures ... 30
2.3 Nursing managers’ attitudes ... 32
2.3.1 Nursing management ... 32
2.3.2 Definition of attitude ... 33
2.3.3 The three dimensions of attitudes ... 34
2.3.4 Literature search on nursing managers’ attitudes ... 35
2.3.5 Nursing managers’ attitudes ... 36
2.4 Summary of current theoretical understanding ... 37
3 AIMS OF THE THESIS ... 39
4 METHODS ... 40
4.1 Setting ... 40
4.2 Design ... 40
4.3 Literature review (original study I) ... 40
4.3.1 Aim and method ... 40
4.3.2 Literature search ... 40
4.3.3 Data evaluation... 41
4.3.4 Data analysis ... 41
4.4 Register study (original study II) ... 41
4.4.1 Aim ... 41
4.4.2 Sample and data collection ... 42
4.4.3 Data analysis ... 42
4.5 Survey (original studies III and IV)... 43
4.5.1 Aim ... 43
4.5.2 Instrument ... 43
4.5.3 Sample and data collection ... 43
4.5.4 Data analysis ... 44
4.6 Associations between the number of seclusion episodes and nursing managers’ attitudes (original study IV) ... 44
4.6.1 Aim ... 44
4.6.2 Sample and data collection ... 45
4.6.3 Data analysis ... 45
4.7 Associations between the duration of seclusion episodes, number and duration of mechanical and physical restraint episodes, number of involuntary medication events, and nursing managers’ attitudes (summary) ... 46
4.7.1 Aim ... 46
4.7.2 Sample and data collection ... 46
4.7.3 Data analysis ... 46
4.8 Ethical issues ... 47
5 RESULTS ... 48
5.1 Nursing staff’s attitudes towards containment methods (original study I) ... 48
5.2 Use of seclusion, restraint, and involuntery medication in psychiatric inpatient care (original study II) ... 51
5.3 Nursing managers’ attitudes towards containment methods (original study III) 52 5.4 Number of seclusion episodes and nursing managers’ attitudes (original study IV) ... 54
5.5 Duration of seclusion episodes, number and duration of mechanical and physical restraint episodes, number of involuntary medication events, and nursing managers’ attitudes towards containment measures (Summary) .... 57
5.5.1 Duration of seclusion episodes and nursing managers’ attitudes towards containment methods ... 57
5.5.2 Use of mechanical restraint and nursing managers’ attitudes towards containment methods ... 58
5.5.3 Use of physical restraint and nursing managers’ attitudes towards containment methods ... 59
5.5.4 Use of involuntary medication and nursing managers’ attitudes towards containment methods ... 61
6 DISCUSSION ... 62
6.1 Main results ... 62
6.1.1 Nursing staff attitudes towards containment methods (Original study I) 62 6.1.2 Use of seclusion, restraint, and involuntary medication in Finland (Original study II) ... 63
6.1.3 Nursing managers’ attitudes towards containment methods (Original study III) ... 63
6.1.4 Number of seclusion episodes and nursing managers’ attitudes (Original study IV)... 64
6.1.5 Duration of seclusion episodes, number and duration of mechanical and physical restraint episodes, number of involuntary medication events, and nursing managers’ attitudes (Summary) ... 66
6.2 Limitations and strengths ... 67
6.2.1 Literature review... 67
6.2.2 Register study ... 67
6.2.3 Survey ... 68
6.2.4 Statistical analysis ... 69
7 CONCLUSIONS ... 70
REFERENCES... 73
APPENDICES ... 87
4.5.2 Instrument ... 43
4.5.3 Sample and data collection ... 43
4.5.4 Data analysis ... 44
4.6 Associations between the number of seclusion episodes and nursing managers’ attitudes (original study IV) ... 44
4.6.1 Aim ... 44
4.6.2 Sample and data collection ... 45
4.6.3 Data analysis ... 45
4.7 Associations between the duration of seclusion episodes, number and duration of mechanical and physical restraint episodes, number of involuntary medication events, and nursing managers’ attitudes (summary) ... 46
4.7.1 Aim ... 46
4.7.2 Sample and data collection ... 46
4.7.3 Data analysis ... 46
4.8 Ethical issues ... 47
5 RESULTS ... 48
5.1 Nursing staff’s attitudes towards containment methods (original study I) ... 48
5.2 Use of seclusion, restraint, and involuntery medication in psychiatric inpatient care (original study II) ... 51
5.3 Nursing managers’ attitudes towards containment methods (original study III) 52 5.4 Number of seclusion episodes and nursing managers’ attitudes (original study IV) ... 54
5.5 Duration of seclusion episodes, number and duration of mechanical and physical restraint episodes, number of involuntary medication events, and nursing managers’ attitudes towards containment measures (Summary) .... 57
5.5.1 Duration of seclusion episodes and nursing managers’ attitudes towards containment methods ... 57
5.5.2 Use of mechanical restraint and nursing managers’ attitudes towards containment methods ... 58
5.5.3 Use of physical restraint and nursing managers’ attitudes towards containment methods ... 59
5.5.4 Use of involuntary medication and nursing managers’ attitudes towards containment methods ... 61
6 DISCUSSION ... 62
6.1 Main results ... 62
6.1.1 Nursing staff attitudes towards containment methods (Original study I) 62 6.1.2 Use of seclusion, restraint, and involuntary medication in Finland (Original study II) ... 63
6.1.3 Nursing managers’ attitudes towards containment methods (Original study III) ... 63
6.1.4 Number of seclusion episodes and nursing managers’ attitudes (Original study IV)... 64
6.1.5 Duration of seclusion episodes, number and duration of mechanical and physical restraint episodes, number of involuntary medication events, and nursing managers’ attitudes (Summary) ... 66
6.2 Limitations and strengths ... 67
6.2.1 Literature review... 67
6.2.2 Register study ... 67
6.2.3 Survey ... 68
6.2.4 Statistical analysis ... 69
7 CONCLUSIONS ... 70
REFERENCES... 73
APPENDICES ... 87
ABBREVIATIONS
ACMQ Attitudes to Containment Measures Questionnaire ANB Augmented Naive Bayes IM coerced intramuscular
NB2 negative binomial regression model
PRN pro re nata, as needed
ABBREVIATIONS
ACMQ Attitudes to Containment Measures Questionnaire ANB Augmented Naive Bayes IM coerced intramuscular
NB2 negative binomial regression model
PRN pro re nata, as needed
1 INTRODUCTION
Mental disorders constitute a major public health challenge in Europe. In many countries, mental health issues, such as depression or schizophrenia, are the main causes for early retirement and disability, and a major burden to economies. More than one-third of the European population is affected by mental health problems each year, while about 1-2% of the European population has been diagnosed with psychotic disorders. (WHO 2015.)
Finland has the highest estimated incidence of mental health problems in Europe, which causes a significant economic burden (Hewlett & Cornford 2019). About 43% of social welfare benefits and disability pensions in Finland are the result of mental disorders (WHO 2015). For example, about one tenth of Finnish adult population suffers from depression (Markkula et al. 2015), and the lifetime prevalence of psychotic disorders is estimated to be about 3.5% in Finland (Suvisaari et al. 2012). The most common psychotic disorder is schizophrenia, with the prevalence of 1.0% (Suvisaari et al. 2012). Psychotic disorders are also the most common reason for psychiatric
inpatient care (Martikainen & Järvelin 2019; Vainio et al. 2018).
In relation to population, Finland also has a high number of mental or behavioral disorder-related patient discharges from inpatient care in comparison to other
European countries (Eurostat 2019). In 2017, a total of 195,406 patients were treated in Finnish specialized psychiatric care, while a total of 24,495 patients received specialized psychiatric inpatient care. This represents 44 patients per 10,000 inhabitants receiving specialized psychiatric inpatient care, with the treatment resulting in an average
hospital stay of 31 days. (Martikainen & Järvelin 2019; Vainio et al. 2018.) In Finland, the number of psychiatrists per capita is one of the highest in Europe, with about 24 psychiatrists per 100,000 inhabitants (Eurostat 2019). In addition, in 2018, there were about 116,000 registered nurses, 172,500 health care practical nurses, 4,300 mental nurses, and 2,600 mental health nurses in Finland (Finnish Institute for Health and Welfare 2020a). About 55% of specialized health care staff are nursing staff (Ministry of Social Affairs and Health 2009).
Especially on acute psychiatric wards, patient aggression is a widespread problem (Abderhalden et al. 2006). Psychiatric disorders, particularly schizophrenia, are
associated with violent behavior (Iozzino et al. 2015; Rueve & Welton 2008; Walsh et al.
2002), but these disorders alone cannot explain violence, as the main predictors of violence seem to be related to socio-demographic and socio-economic factors (Stuart 2003). Substance abuse, alone or as a comorbidity, was shown to be strongly related to violent behavior (Rueve & Welton 2008), while Kuivalainen et al. (2017a) suggested that
1 INTRODUCTION
Mental disorders constitute a major public health challenge in Europe. In many countries, mental health issues, such as depression or schizophrenia, are the main causes for early retirement and disability, and a major burden to economies. More than one-third of the European population is affected by mental health problems each year, while about 1-2% of the European population has been diagnosed with psychotic disorders. (WHO 2015.)
Finland has the highest estimated incidence of mental health problems in Europe, which causes a significant economic burden (Hewlett & Cornford 2019). About 43% of social welfare benefits and disability pensions in Finland are the result of mental disorders (WHO 2015). For example, about one tenth of Finnish adult population suffers from depression (Markkula et al. 2015), and the lifetime prevalence of psychotic disorders is estimated to be about 3.5% in Finland (Suvisaari et al. 2012). The most common psychotic disorder is schizophrenia, with the prevalence of 1.0% (Suvisaari et al. 2012). Psychotic disorders are also the most common reason for psychiatric
inpatient care (Martikainen & Järvelin 2019; Vainio et al. 2018).
In relation to population, Finland also has a high number of mental or behavioral disorder-related patient discharges from inpatient care in comparison to other
European countries (Eurostat 2019). In 2017, a total of 195,406 patients were treated in Finnish specialized psychiatric care, while a total of 24,495 patients received specialized psychiatric inpatient care. This represents 44 patients per 10,000 inhabitants receiving specialized psychiatric inpatient care, with the treatment resulting in an average
hospital stay of 31 days. (Martikainen & Järvelin 2019; Vainio et al. 2018.) In Finland, the number of psychiatrists per capita is one of the highest in Europe, with about 24 psychiatrists per 100,000 inhabitants (Eurostat 2019). In addition, in 2018, there were about 116,000 registered nurses, 172,500 health care practical nurses, 4,300 mental nurses, and 2,600 mental health nurses in Finland (Finnish Institute for Health and Welfare 2020a). About 55% of specialized health care staff are nursing staff (Ministry of Social Affairs and Health 2009).
Especially on acute psychiatric wards, patient aggression is a widespread problem (Abderhalden et al. 2006). Psychiatric disorders, particularly schizophrenia, are
associated with violent behavior (Iozzino et al. 2015; Rueve & Welton 2008; Walsh et al.
2002), but these disorders alone cannot explain violence, as the main predictors of violence seem to be related to socio-demographic and socio-economic factors (Stuart 2003). Substance abuse, alone or as a comorbidity, was shown to be strongly related to violent behavior (Rueve & Welton 2008), while Kuivalainen et al. (2017a) suggested that
it is nearly impossible to identify single predictors for inpatient violence. There is previous evidence that violence in psychiatric inpatient care is usually related to male gender, schizophrenia, substance abuse, and violent behavior in the past (Iozzino et al.
2015). Inpatient violence during involuntary psychiatric care often results in the limitation of a patient’s fundamental rights, that is, utilization of coercive measures (Kuivalainen et al. 2017a).
Coercion is regularly used in psychiatric care to manage patients’ violent,
aggressive, and disturbed behavior (Price et al. 2017; Cleary et al. 2010) even though coercive measures can have negative effects on patients and staff (McLaughlin et al.
2016; Sailas & Wahlbeck 2005). The coercive measures most commonly used in Finland are seclusion, mechanical restraint, physical restraint, and involuntary medication (Martikainen & Järvelin 2019; Vainio et al. 2018; Rainio & Räty 2015). These measures are most often applied due to harmful behavior (Kuivalainen et al. 2017b; Raboch et al.
2010), agitation, and confusion (Larue et al. 2009; Keski-Valkama et al. 2010).
Various countries differ noticeably in the use of coercive measures (Al-Maraira &
Hayajneh 2019; Bak & Aggernæs 2012; Steinert et al 2010), yet comparisons concerning their use are challenging due to framework, cultural, historical, nursing, legislative, and economic differences (Bak & Aggernæs 2012). In addition, differences in how the use of coercive measures is monitored makes these comparisons even more difficult (Janssen et al. 2011).
In Finland, coercive measures in psychiatric care have been widely studied. For example, both Tuohimäki (2007) and Kuosmanen (2009) examined the deprivation of liberty in psychiatric care. Coercion and the use of coercive measures in child or adolescent psychiatric care were studied by Kauppila (2019), Siponen et al. (2011), and Ellilä et al. (2008). Tuovinen (2017) investigated hospital violence, seclusion and restraint practices in a forensic psychiatric hospital. In addition, Keski-Valkama (2010) investigated the use of seclusion and mechanical restraint at international, national, and individual levels, while Kontio (2011) examined seclusion and restraint practices along with how an e-learning course affected the competencies of psychiatric nurses.
On the other hand, Soininen (2014) examined the quality of life and perception of care among patients who had been subjected to coercion, while Korkeila et al. (2009) concentrated on the heavy use of coercive measures. However, based on current knowledge, studies concerning coercive measures that utilize ward-level data at national level have not been conducted previously.
Usually, patients experience coercive measures to be negative (Al-Maraira &
Hayajneh 2019; Aquilera-Serrano et al. 2018; Kontio et al. 2012; Wallsten & Kjellin 2007). Furthermore, Soininen et al. (2013) found that patients consider the use of seclusion and restraint as neither necessary nor beneficial. Patients’ attitudes towards
coercive measures are also more negative than the attitudes of health care professionals (Reisch et al. 2018). The patient’s subjective experience of coercive measures will be influenced by the information provided by the staff, interaction and contact with the staff, communication with health care professionals, and the quality of the physical and working environment (Aquilera-Serrano et al. 2018).
The attitudes of professionals, e.g., nursing staff, can have a large effect on the use of coercive measures (Happell & Harrow 2010; Zinkler & Priebe 2002). After all, nursing staff members are often the ones that apply these measures in clinical practice (Happell et al., 2012) and, as such, have an essential role in decision-making concerning the use of coercive measures (Riahi et al. 2016; Marangos-Frost & Wells 2000). For this reason, any research into the decision-making process concerning the use of coercive
measures should explicitly take into account nursing staff perceptions towards these practices.
In the clinical environment, nursing staff observe patient behavior, evaluate risks, and use de-escalation interventions prior to applying coercive measures (Laiho et al.
2013). Nurses’ decisions on the use of coercive measures are affected by ethical and safety guidelines, staff-related factors, and interpersonal factors (Riahi et al. 2016). In addition, the process is affected by the patient’s behavior and previous experiences of challenging situations (Laiho et al. 2013). According to previous research, some Finnish psychiatric nurses consider the use of coercive measures as ethically problematic (Lind et al. 2004).
The reduction of coercion and coercive measures has been an international objective in psychiatric care for many years (Gooding et al. 2020; Väkiparta et al. 2019:
Gooding et al. 2018). Notably, ‘mental health rights’ was identified as one of five focus areas in the Finnish National Mental Health Strategy 2020–2030. Mental health rights are based on human rights and the Constitution of Finland, and are intended to protect everyone’s mental health. Within the Finnish National Mental Health Strategy for 2020- 2030, legislative reform and the reduction of coercion are two specific measures for ensuring citizens’ mental health rights. (Vorma et al. 2020.) It is important to note that Putkonen et al. (2013) found that the reduction of seclusion and restraint does not lead to an increase in hospital violence.
Previous reviews have identified several strategies for the reduction of coercion (Gooding et al 2020; Hirsch & Steinert 2019; Väkiparta et al. 2019; Gooding et al. 2018;
Goulet et al. 2017). For an organization to successfully reduce coercion, all of the measures must be implemented at all levels of the organization (Hirsch & Steinert 2019; Kuosmanen & Laukkanen 2019). Many programs aiming to reduce coercion have been effective (Gooding et al. 2020; Hirsch & Steinert 2019), but the Six Core Strategies by Huckshorn (2014; 2004) have been implemented most frequently in psychiatric care
it is nearly impossible to identify single predictors for inpatient violence. There is previous evidence that violence in psychiatric inpatient care is usually related to male gender, schizophrenia, substance abuse, and violent behavior in the past (Iozzino et al.
2015). Inpatient violence during involuntary psychiatric care often results in the limitation of a patient’s fundamental rights, that is, utilization of coercive measures (Kuivalainen et al. 2017a).
Coercion is regularly used in psychiatric care to manage patients’ violent,
aggressive, and disturbed behavior (Price et al. 2017; Cleary et al. 2010) even though coercive measures can have negative effects on patients and staff (McLaughlin et al.
2016; Sailas & Wahlbeck 2005). The coercive measures most commonly used in Finland are seclusion, mechanical restraint, physical restraint, and involuntary medication (Martikainen & Järvelin 2019; Vainio et al. 2018; Rainio & Räty 2015). These measures are most often applied due to harmful behavior (Kuivalainen et al. 2017b; Raboch et al.
2010), agitation, and confusion (Larue et al. 2009; Keski-Valkama et al. 2010).
Various countries differ noticeably in the use of coercive measures (Al-Maraira &
Hayajneh 2019; Bak & Aggernæs 2012; Steinert et al 2010), yet comparisons concerning their use are challenging due to framework, cultural, historical, nursing, legislative, and economic differences (Bak & Aggernæs 2012). In addition, differences in how the use of coercive measures is monitored makes these comparisons even more difficult (Janssen et al. 2011).
In Finland, coercive measures in psychiatric care have been widely studied. For example, both Tuohimäki (2007) and Kuosmanen (2009) examined the deprivation of liberty in psychiatric care. Coercion and the use of coercive measures in child or adolescent psychiatric care were studied by Kauppila (2019), Siponen et al. (2011), and Ellilä et al. (2008). Tuovinen (2017) investigated hospital violence, seclusion and restraint practices in a forensic psychiatric hospital. In addition, Keski-Valkama (2010) investigated the use of seclusion and mechanical restraint at international, national, and individual levels, while Kontio (2011) examined seclusion and restraint practices along with how an e-learning course affected the competencies of psychiatric nurses.
On the other hand, Soininen (2014) examined the quality of life and perception of care among patients who had been subjected to coercion, while Korkeila et al. (2009) concentrated on the heavy use of coercive measures. However, based on current knowledge, studies concerning coercive measures that utilize ward-level data at national level have not been conducted previously.
Usually, patients experience coercive measures to be negative (Al-Maraira &
Hayajneh 2019; Aquilera-Serrano et al. 2018; Kontio et al. 2012; Wallsten & Kjellin 2007). Furthermore, Soininen et al. (2013) found that patients consider the use of seclusion and restraint as neither necessary nor beneficial. Patients’ attitudes towards
coercive measures are also more negative than the attitudes of health care professionals (Reisch et al. 2018). The patient’s subjective experience of coercive measures will be influenced by the information provided by the staff, interaction and contact with the staff, communication with health care professionals, and the quality of the physical and working environment (Aquilera-Serrano et al. 2018).
The attitudes of professionals, e.g., nursing staff, can have a large effect on the use of coercive measures (Happell & Harrow 2010; Zinkler & Priebe 2002). After all, nursing staff members are often the ones that apply these measures in clinical practice (Happell et al., 2012) and, as such, have an essential role in decision-making concerning the use of coercive measures (Riahi et al. 2016; Marangos-Frost & Wells 2000). For this reason, any research into the decision-making process concerning the use of coercive
measures should explicitly take into account nursing staff perceptions towards these practices.
In the clinical environment, nursing staff observe patient behavior, evaluate risks, and use de-escalation interventions prior to applying coercive measures (Laiho et al.
2013). Nurses’ decisions on the use of coercive measures are affected by ethical and safety guidelines, staff-related factors, and interpersonal factors (Riahi et al. 2016). In addition, the process is affected by the patient’s behavior and previous experiences of challenging situations (Laiho et al. 2013). According to previous research, some Finnish psychiatric nurses consider the use of coercive measures as ethically problematic (Lind et al. 2004).
The reduction of coercion and coercive measures has been an international objective in psychiatric care for many years (Gooding et al. 2020; Väkiparta et al. 2019:
Gooding et al. 2018). Notably, ‘mental health rights’ was identified as one of five focus areas in the Finnish National Mental Health Strategy 2020–2030. Mental health rights are based on human rights and the Constitution of Finland, and are intended to protect everyone’s mental health. Within the Finnish National Mental Health Strategy for 2020- 2030, legislative reform and the reduction of coercion are two specific measures for ensuring citizens’ mental health rights. (Vorma et al. 2020.) It is important to note that Putkonen et al. (2013) found that the reduction of seclusion and restraint does not lead to an increase in hospital violence.
Previous reviews have identified several strategies for the reduction of coercion (Gooding et al 2020; Hirsch & Steinert 2019; Väkiparta et al. 2019; Gooding et al. 2018;
Goulet et al. 2017). For an organization to successfully reduce coercion, all of the measures must be implemented at all levels of the organization (Hirsch & Steinert 2019; Kuosmanen & Laukkanen 2019). Many programs aiming to reduce coercion have been effective (Gooding et al. 2020; Hirsch & Steinert 2019), but the Six Core Strategies by Huckshorn (2014; 2004) have been implemented most frequently in psychiatric care
and, therefore, provides the most evidence (Goulet et al. 2017). Leadership across all levels of an organization plays a main role in the reduction of coercion (Goulet et al.
2017; Gooding et al. 2018; Huckshorn 2014; Huckshorn 2004). However, based on current knowledge, leadership and management in the reduction of coercion have not been studied previously.
Within psychiatric care, nursing management and leadership are two challenging areas of work due to the constantly changing environment (Holm & Severinsson 2010).
Based on previous studies, leadership and management are associated with both the quality of care and nursing outcomes (Wong et al. 2013; Sfantou et al. 2017; Aiken et al.
2012). In addition, supportive nursing management is associated with positive nursing outcomes (Gunnarsdóttir et al. 2009; Aiken 2002; Kramer & Schmalenberg 2002), while the ward atmosphere is influenced by management policies (Asikainen et al. 2020). It should be noted that employees notice a manager’s attitude faster than they can recognize the manager’s actions (Weiss & Tappen 2015).
The aim of this thesis is to examine the use of seclusion, restraint, and involuntary medication in Finland and evaluate psychiatric nursing managers’ attitudes towards the use of containment methods. In addition, the associations between nursing managers’
attitudes and the use of coercive measures are examined.
2 REVIEW OF THE LITERATURE
2.1 PSYCHIATRIC CARE IN FINLAND
In Finland, municipalities organize the mental health services in their area as a part of public health work and social welfare. Joint municipal boards for hospital districts arrange mental health services that are considered to be specialized medical care in their area. Some mental health services are organized by the Basic Public Services, while joint municipal boards for hospital districts and the health centres operating in the districts cooperate with the municipal social welfare department to provide specialized services. (Mental Health Act 1116/1990.) A total of 20 hospital districts operate within the Finnish mainland (Act on Specialized Medical Care 1062/1989).
The Finnish Ministry of Social Affairs and Health is responsible for the supervision, direction, and general planning of mental health work. The Regional State
Administrative Agency is in charge of these aspects of care within its area of operation and is guided by The National Supervisory Authority for Welfare and Health under the Ministry of Social Affairs and Health. (Mental Health Act 1116/1990; Act on Specialized Medical Care 1062/1989.)
During the last decade, the total number of psychiatric patients has increased, while both the proportion of psychiatric patients in inpatient care and the duration of inpatient admissions have decreased. The most common reasons for inpatient care are affective disorders and schizophrenia. (Martikainen & Järvelin 2019; Vainio et al. 2018.) A total of 8461 involuntary admissions were reported in Finnish psychiatric care in 2017 (Finnish Institute for Health and Welfare 2020b). According to the Finnish Mental Health Act (1116/1990), involuntary admission to a psychiatric hospital is possible if:
1) the patient is mentally ill
2) the patient needs treatment for a mental illness and without treatment the situation would become considerably worse, or the patient would endanger his/her or other people’s health or safety
3) other mental health services are insufficient or unsuitable.
During involuntary treatment or examination, a patient’s fundamental rights and right of self-determination can be limited if it is unquestionably necessary (Mental Health Act 1116/1990).
and, therefore, provides the most evidence (Goulet et al. 2017). Leadership across all levels of an organization plays a main role in the reduction of coercion (Goulet et al.
2017; Gooding et al. 2018; Huckshorn 2014; Huckshorn 2004). However, based on current knowledge, leadership and management in the reduction of coercion have not been studied previously.
Within psychiatric care, nursing management and leadership are two challenging areas of work due to the constantly changing environment (Holm & Severinsson 2010).
Based on previous studies, leadership and management are associated with both the quality of care and nursing outcomes (Wong et al. 2013; Sfantou et al. 2017; Aiken et al.
2012). In addition, supportive nursing management is associated with positive nursing outcomes (Gunnarsdóttir et al. 2009; Aiken 2002; Kramer & Schmalenberg 2002), while the ward atmosphere is influenced by management policies (Asikainen et al. 2020). It should be noted that employees notice a manager’s attitude faster than they can recognize the manager’s actions (Weiss & Tappen 2015).
The aim of this thesis is to examine the use of seclusion, restraint, and involuntary medication in Finland and evaluate psychiatric nursing managers’ attitudes towards the use of containment methods. In addition, the associations between nursing managers’
attitudes and the use of coercive measures are examined.
2 REVIEW OF THE LITERATURE
2.1 PSYCHIATRIC CARE IN FINLAND
In Finland, municipalities organize the mental health services in their area as a part of public health work and social welfare. Joint municipal boards for hospital districts arrange mental health services that are considered to be specialized medical care in their area. Some mental health services are organized by the Basic Public Services, while joint municipal boards for hospital districts and the health centres operating in the districts cooperate with the municipal social welfare department to provide specialized services. (Mental Health Act 1116/1990.) A total of 20 hospital districts operate within the Finnish mainland (Act on Specialized Medical Care 1062/1989).
The Finnish Ministry of Social Affairs and Health is responsible for the supervision, direction, and general planning of mental health work. The Regional State
Administrative Agency is in charge of these aspects of care within its area of operation and is guided by The National Supervisory Authority for Welfare and Health under the Ministry of Social Affairs and Health. (Mental Health Act 1116/1990; Act on Specialized Medical Care 1062/1989.)
During the last decade, the total number of psychiatric patients has increased, while both the proportion of psychiatric patients in inpatient care and the duration of inpatient admissions have decreased. The most common reasons for inpatient care are affective disorders and schizophrenia. (Martikainen & Järvelin 2019; Vainio et al. 2018.) A total of 8461 involuntary admissions were reported in Finnish psychiatric care in 2017 (Finnish Institute for Health and Welfare 2020b). According to the Finnish Mental Health Act (1116/1990), involuntary admission to a psychiatric hospital is possible if:
1) the patient is mentally ill
2) the patient needs treatment for a mental illness and without treatment the situation would become considerably worse, or the patient would endanger his/her or other people’s health or safety
3) other mental health services are insufficient or unsuitable.
During involuntary treatment or examination, a patient’s fundamental rights and right of self-determination can be limited if it is unquestionably necessary (Mental Health Act 1116/1990).
2.2 COERCIVE MEASURES
2.2.1 Definition of coercive measures
Coercion can be defined as a health care professional’s action against a patient’s denoted wishes (Olofsson et al. 1998). Coercion also entails the use of force to limit a person’s preferences (Wynn 2006). Usually, coercion in psychiatric care is specified as a form of formal coercion, such as seclusion or restraint (Verbeke et al. 2019; McLaughlin et al. 2016; Bowers 2006), or involuntary medication (Muir-Cochrane et al. 2020;
McLaughlin et al. 2016). The use of coercion is usually regulated by national law (Elmer et al. 2018), as well as formally decided upon and documented (Hem et al. 2018).
However, interventions not considered as formal coercion can also violate a patient’s autonomy (Valenti et al. 2015). This informal coercion, which includes practices such as persuasion or leverage, is not regulated by law and can, in certain cases, be used deliberately (Elmer et al. 2018).
In this thesis, coercive measures refer especially to the practices of seclusion, mechanical restraint, physical restraint, and involuntary medication within psychiatric care. The use and documentation of these measures is regulated by the Finnish Mental Health Act (1116/1990), and the application of these measures has been systematically reported on the national level for many years (Vainio et al. 2018; Rainio & Räty 2015).
The definitions of coercive measures applied throughout this thesis are presented in Table 1. The concept of restraint is often utilized incoherently in the literature, as it can refer to mechanical restraint, physical restraint (Al-Maraira & Hayajneh 2019), or chemical restraint (Muir-Cochrane et al. 2020), for example. In this thesis, the concepts of mechanical restraint and physical restraint are adopted.
The concept of containment methods offers a wider perspective of coercion.
Containment can refer to actions taken by staff to keep patients safe, but which are usually characterized by separation, intrusion, and restriction (Bowers 2006). In addition to seclusion, restraint, and involuntary medication, containment methods include pro re nata (PRN) medication, intermittent and constant observation, transfer to a specialist locked ward, timeout, net bed, and open area seclusion (Bowers et al. 2007; Bowers 2006).
Table 1. The definitions of coercive measures applied throughout this thesis.
Method Definition
Seclusion Involuntary isolation of a patient in a room that is locked (American Psychiatric Nurses Association 2014; Sailas & Wahlbeck 2005) Mechanical restraint
The use of restraining equipment to limit the patient’s movement (Allen et al. 2019; Steinert & Lepping 2009; Sailas & Wahlbeck
2005)
Physical restraint Physically holding the patient to prevent them from moving (Steinert & Lepping
2009
Involuntary medication Application of medication by force or by psychological pressure (Steinert & Lepping
2009 2.2.2 Coercive measures in Finland
In Finland, the use of coercion and coercive measures in psychiatric care is regulated by the Mental Health Act (1116/1990). A physician is in charge of ordering coercive measures, but during sudden situations nursing staff members are entitled to begin seclusion or restraint without the presence of a physician; however, a physician must be informed of these decisions immediately (Mental Health Act 1116/1990).
According to the Finnish legislation (Mental Health Act 1116/1990), permitted measures which limit a patient’s self-determination or fundamental rights during involuntary treatment or examination are:
1) involuntary treatment of mental illness (including involuntary medication) 2) involuntary treatment of physical illness
3) limitation of movement 4) seclusion
5) physical restraint 6) mechanical restraint
7) possession of personal property 8) checking a patient’s possessions 9) frisk and bodily search
10) limiting contact
Data concerning the use of coercive measures are regularly collected at the national level. However, before the year 2017, only data concerning seclusion, mechanical
2.2 COERCIVE MEASURES
2.2.1 Definition of coercive measures
Coercion can be defined as a health care professional’s action against a patient’s denoted wishes (Olofsson et al. 1998). Coercion also entails the use of force to limit a person’s preferences (Wynn 2006). Usually, coercion in psychiatric care is specified as a form of formal coercion, such as seclusion or restraint (Verbeke et al. 2019; McLaughlin et al. 2016; Bowers 2006), or involuntary medication (Muir-Cochrane et al. 2020;
McLaughlin et al. 2016). The use of coercion is usually regulated by national law (Elmer et al. 2018), as well as formally decided upon and documented (Hem et al. 2018).
However, interventions not considered as formal coercion can also violate a patient’s autonomy (Valenti et al. 2015). This informal coercion, which includes practices such as persuasion or leverage, is not regulated by law and can, in certain cases, be used deliberately (Elmer et al. 2018).
In this thesis, coercive measures refer especially to the practices of seclusion, mechanical restraint, physical restraint, and involuntary medication within psychiatric care. The use and documentation of these measures is regulated by the Finnish Mental Health Act (1116/1990), and the application of these measures has been systematically reported on the national level for many years (Vainio et al. 2018; Rainio & Räty 2015).
The definitions of coercive measures applied throughout this thesis are presented in Table 1. The concept of restraint is often utilized incoherently in the literature, as it can refer to mechanical restraint, physical restraint (Al-Maraira & Hayajneh 2019), or chemical restraint (Muir-Cochrane et al. 2020), for example. In this thesis, the concepts of mechanical restraint and physical restraint are adopted.
The concept of containment methods offers a wider perspective of coercion.
Containment can refer to actions taken by staff to keep patients safe, but which are usually characterized by separation, intrusion, and restriction (Bowers 2006). In addition to seclusion, restraint, and involuntary medication, containment methods include pro re nata (PRN) medication, intermittent and constant observation, transfer to a specialist locked ward, timeout, net bed, and open area seclusion (Bowers et al. 2007; Bowers 2006).
Table 1. The definitions of coercive measures applied throughout this thesis.
Method Definition
Seclusion Involuntary isolation of a patient in a room that is locked (American Psychiatric Nurses Association 2014; Sailas & Wahlbeck 2005) Mechanical restraint
The use of restraining equipment to limit the patient’s movement (Allen et al. 2019;
Steinert & Lepping 2009; Sailas & Wahlbeck 2005)
Physical restraint Physically holding the patient to prevent them from moving (Steinert & Lepping
2009
Involuntary medication Application of medication by force or by psychological pressure (Steinert & Lepping
2009 2.2.2 Coercive measures in Finland
In Finland, the use of coercion and coercive measures in psychiatric care is regulated by the Mental Health Act (1116/1990). A physician is in charge of ordering coercive measures, but during sudden situations nursing staff members are entitled to begin seclusion or restraint without the presence of a physician; however, a physician must be informed of these decisions immediately (Mental Health Act 1116/1990).
According to the Finnish legislation (Mental Health Act 1116/1990), permitted measures which limit a patient’s self-determination or fundamental rights during involuntary treatment or examination are:
1) involuntary treatment of mental illness (including involuntary medication) 2) involuntary treatment of physical illness
3) limitation of movement 4) seclusion
5) physical restraint 6) mechanical restraint
7) possession of personal property 8) checking a patient’s possessions 9) frisk and bodily search
10) limiting contact
Data concerning the use of coercive measures are regularly collected at the national level. However, before the year 2017, only data concerning seclusion, mechanical
