Nurses' and Physicians' Educational Needs in Seclusion and Restraint Practices

Nurses’ and Physicians’ Educational Needs inSeclusion and Restraint Practicesppc_222 198..207

Raija Kontio, RN, MSN, Maritta Välimäki, RN, PhD, Hanna Putkonen, MD, PhD,Angela Cocoman, RPN, MSc, Saija Turpeinen, RN, MSN, Lauri Kuosmanen, RN, MSN,and Grigori Joffe, MD, PhD

PURPOSE. This study aimed to explore nurses’

(N = 22) and physicians’ (N = 5) educational

needs in the context of their perceived seclusion

and restraint-related mode of action and need for

support.

METHOD. The data were collected by focus group

(N = 4) interviews and analyzed with inductive

content analysis.

RESULTS. Participants recognized a need for

on-ward and problem-based education and

infrastructural and managerial support. The

declared high ethical principles were not in

accordance with the participants’ reliance on

manpower and the high seclusion and restraint

rates.

PRACTICE IMPLICATIONS. Future educational

programs should bring together written clinical

guidelines, education on ethical and legal issues,

and the staff’s support aspect.

Search terms: Educational need, mode of action,

psychiatric care, restraint, seclusion, support

Raija Kontio, RN, MSN, is a Doctoral Student/Director ofNursing, University of Turku, Department of NursingScience, Turku, Finland, and Hospital District of Helsinkiand Uusimaa, Hyvinkää Hospital Region, KellokoskiHospital, Tuusula, Finland; Maritta Välimäki, RN, PhD,is a Professor/Director of Nursing, University of Turku,Department of Nursing Science, Turku, Finland, andHospital District of Southern Finland, Turku, Finland;Hanna Putkonen, MD, PhD, is a Senior Researcher,Vanha Vaasa Hospital, Vaasa, Finland; Angela Cocoman,RPN, MSc, is a Lecturer, Dublin City University, Schoolof Nursing, Dublin, Ireland; Saija Turpeinen, RN, MSN,is a Head Nurse, Hospital District of Helsinki andUusimaa, Hyvinkää Hospital Region, Kellokoski Hospital,Tuusula, Finland; Lauri Kuosmanen, RN, MSN, is aDoctoral Student/Project Manager, University of Turku,Department of Nursing Science, Turku, Finland, andPrimary Health Care Organisation of City of Vantaa,Vantaa, Finland; and Grigori Joffe, MD, PhD, is Chief ofDepartment of Psychiatry, Hospital District of Helsinkiand Uusimaa, Helsinki University Central Hospital,Helsinki, Finland.

Methods of seclusion and restraint have been usedin psychiatric settings in order to restrict the challeng-ing behavior of patients who are expressing psychoticepisodes (Niveau, 2004). Sailas and Fenton (2000) havedefined seclusion as isolation of patients in a single,locked, unfurnished room where the patient can bemonitored by nurses and from which they cannot leaveat will, and mechanical restraint as tying a patient ontoa bed with bands and belts.

Seclusion, restraint, and other compulsory restric-tions (e.g., prohibition to leave the ward, temporaryconfiscation of personal property) present a complexdilemma for the healthcare staff because they call intoquestion patients’ self-determination and humanrights, and the legal and ethical responsibilities ofthe staff (World Health Organization [WHO], 2006).

First received October 29, 2008; Revision received February 26,2009; Accepted for publication March 1, 2009.

198 Perspectives in Psychiatric Care Vol. 45, No. 3, July 2009

Furthermore, Sailas and Wahlbeck (2005) have arguedthat the healthcare staff itself has often perceived seclu-sion and restraint as beneficial to the patient—an atti-tude that has changed little in the past few years. Onthe other hand, staff and patients may have differingperceptions of the effects of seclusion and restrainton patients’ well-being, and this inconsistency mayresult in a lack of collaboration between staff andpatients (Foster, Bowers, & Nijman, 2007). At the sametime, seclusion and restraint have been shown to havedeleterious physical or psychological effects on boththe patient and the staff (Frueh, Cusack, Grubaugh,Sauvageot, & Cousins, 2005). Further, the staff haveperceived seclusion and restraint as ethically problem-atic situations (Lind, Kaltiala-Heino, Suominen, Leino-Kilpi, & Välimäki, 2004; Marangos-Frost & Wells, 2000;Sclafani et al., 2008).

In general, ethically, high-standard treatmentrequires professionally skilled and committed staff(Kisely, Campbell, & Preston, 2005; Perraud et al.,2006). In this regard, professional competence in psy-chiatric care has been declared to be a major challengein Europe, particularly regarding nursing care forpatients experiencing compulsory restrictions (WHO,2005, 2006). The Council of Europe (2000) also empha-sizes the importance of continuing education in thisfield. Indeed, it has already been shown that educationcan improve the staff’s well-being and work satisfac-tion and decrease exhaustion at work (Gilbody et al.,2006; Nolan & Bradley, 2007). Nevertheless, the quality,content, and methods of continuing professionaleducation for qualified nurses working in Europeanpsychiatric hospitals are fragmentary (Välimäki, Lahti,Scott, & Chambers, 2008; WHO, 2006). Although thereexists a body of literature on educational needs andinterventions related with seclusion and restraint(Gaskin, Elsom, & Happell, 2007), thus far, informationon the staff’s own point of view has been lacking. Thisis especially true for knowledge on the type of educa-tion and support (e.g., psychological compassion orprofessional advice) the staff needs to successfullymanage these ethically challenging situations (Kisely

et al., 2005). For these educational needs to be identi-fied, the staff’s actual mode of action (seclusion- andrestraint-related procedures as usual) should beassessed. We were, however, unable to locate anyreports on seclusion- and restraint-focused educationalneeds explored in parallel with the current mode ofaction. Moreover, support may substantially affect theseclusion and restraint practices (McCue, Urcuyo, Lilu,Tobias, & Chambers, 2004; Wand & Coulson, 2006),but, to the best of our knowledge, data on its interac-tions with education have not been published.

The purpose of this study was to elicit nurses’ andphysicians’ perceptions of their educational needs inthe context of their perceived seclusion- and restraint-related mode of action and their need for support. Theaim of the study was to explore what kind of modes ofaction for aggressive and disturbed patients there arein the unit/hospital and what kind of education andsupport nurses and physicians would like to have inrelation to the management of aggressive and dis-turbed patients. The study was a part of the EuropeanCommission-funded research and developmentproject (Leonardo da Vinci; FI-06-B-F-PP-160701) beingconducted in six European countries and focusing onnurses’ vocational training in the management ofaggressive and disturbed psychiatric inpatients.

Methods

Participants and Data Collection

Because little was known about the topic of interest,a descriptive qualitative approach was used to explorenurses’ and physicians’ perceptions of their educa-tional needs in the context of their perceived seclusion-and restraint-related mode of action and their need forsupport (Burns & Grove, 2005). In healthcare settings,group interaction encourages respondents to exploreand clarify individual and shared perspectives (Tong,Sainsbury, & Craig, 2007). Therefore, a qualitativemethodology with a focus group interview wasselected as a method to elicit information that could

Perspectives in Psychiatric Care Vol. 45, No. 3, July 2009 199

only surface in the context of communication amongnurses and among physicians (Patton, 2007). Focusgroup methodology employs an interview techniquewhere the prime objective is to obtain accurate data ona limited range of specific issues (Robinson, 1999). Incontrast to a survey, where responses are limited, theaim of the focus group method is not to reach ageneralized or representative statement of opinions(Patton). The assumption of the focus group method-ology is rather that opinions are not always readilyavailable and are open to influence by others in aninteractive setting (Robinson). Simple statistics (e.g.,mean, percentage, range) were applied for the demo-graphic characteristics of participants to provide thereaders with a clear description of the focus groups.

The study was carried out on six wards in two psy-chiatric hospitals in southern Finland on March 22–26,2007. The wards were included in the study if theywere acute closed-hospital wards practicing seclusionand restraint. The data were collected from nurses andphysicians working on the study wards during thestudy period. The inclusion criteria were as follows:registered nurses and physicians, adequate commandof Finnish, voluntary participation, and writteninformed consent to participate in the study. Purposivesampling involved the conscious selection of nursesand physicians whose working experience in psychia-try was at least 1 year, who were working on the studywards during the study period, and who had repeat-edly faced aggressive and disturbed patients and prac-ticed seclusion and restraint—common characteristicsthat enabled the gathering of rich, relevant, and diversedata pertinent to the research question (Burns & Grove,2005).

A pilot study on nurses (n = 13) was carried out ontwo acute psychiatric wards to test the suitability offocus group interview for the study phenomena, thefeasibility of the semistructured interview form, andthe definition of the researchers’ role. After the pilotstudy, one of the three questions and the role of theresearchers were revised. The focus group questionswere open ended, allowing the respondents to

describe in their own words their views on seclusionand restraint. The following basic questions wereasked: (a) What kind of mode of action for aggressiveand disturbed patients is there in your unit/hospital?(b) What kind of education would you like to have inrelation to the management of aggressive and dis-turbed patients? (c) What kind of support would youlike to have in relation to the management of aggres-sive and disturbed patients? The additional questionsasked on the mode of action were as follows: “Do youhave any written guidelines for the mode of actionin the unit/hospital?” and “Do you have writtenguidelines/procedures in relation to the managementof aggressive and disturbed patients?”

The study was approved by the ethical committeeand the institutional authorities. After informationabout the study and their own rights were completed,participants gave their written informed consent. Ofthe 22 nurses and 8 physicians invited, all 22 nursesand 6 physicians (2 did not attend the interview) werescreened and included. One physician only attendedthe first 30 min of the interview and was thereforeexcluded from the analysis. The data were collected byfour pretrained researchers in a total of four focusgroups, three groups of nurses (N = 22) and one groupof physicians (N = 5). The professions were split intoseparate focus groups (nurses and physicians), whichfacilitated ventilation of opinions, information, andfeelings within professional groups. The researchershad to study literature on qualitative methodology(e.g., Burns & Grove, 2005; Tong et al., 2007) prior to a4-h focus-group interview seminar, during which themethodology was thoroughly discussed. Exercisesincluded two imaginary cases. The practical trainingwas obtained during the pilot study. There were tworesearchers in each focus group: a moderator, whoserole was to create a nonthreatening, supportive atmo-sphere to encourage the participants to share theirviews, and a researcher, who managed the taperecorder and, if needed, also asked questions. Duringthe interviews, the moderator summarized responsesafter each question and thereby verified the accuracy

Nurses’ and Physicians’ Educational Needs in Seclusion and Restraint Practices


of obtained information (Tong et al.). Each focus groupinterview lasted 80–100 (M = 90) min. The focus groupinterviews were all tape-recorded and transcribed.

Data Analysis

The data obtained from the focus group interviewwere analyzed with inductive content analysis, whichis a process used for analyzing documents systemati-cally and objectively (Burns & Grove, 2005). The unit ofanalysis was an utterance, which could be a sentence orpart of a sentence consisting of thematic content rel-evant to the research question (Burns & Grove; Grane-heim & Lundman, 2004). First, the transcribed text wasread several times after the unit of analysis had beenchosen. Second, reduction of the data was carried outby asking a question and picking out phrases answer-ing that question (basic and detailed questions pre-sented earlier). The third phase was coding, where thereduced phrases were given a description accordingto their thematic content. Fourth, subcategories weredeveloped for these codes, phrased by groupingtogether those with similar content. Finally, main cat-egories were created by grouping subcategories withsimilar meaning (Tong et al., 2007). This form of analy-sis provided coherence and structure for the data,ensuring that the original data were not skewed inany way. The data from nurses and physicians werehandled separately, but, because they were mainlysimilar, the final analysis comprised the whole group(i.e., nurses and physicians together). Two researchersanalyzed the same data set independently and thereaf-ter compared and verified the content and categoriesobtained. In case of discrepancies, consensus wasreached after a thorough discussion.

Results

Background Information on Nurses and Physicians

Participants’ mean age was 44 years (range: 26–59)and mean working experience was 22 years (range:

1–39); 52% were female. A majority had completedupper secondary education. All physicians and 45% ofnurses had received vocational in-service training inmental health care (see Table 1). For the nurses, thevocational in-service training included, for example,courses on the nurse–patient relationship, family andgroup therapy, or management of aggressive patients.

Mode of Action in the Treatment of Aggressive andDisturbed Patients

The participants discussed the mode of action thatguided the practices of seclusion and restraint in theunit/hospital. The discussion showed that physiciansand most nurses emphasized the importance of

Table 1. Background Information on Nurses andPhysicians

Background information (N = 27) n %

ProfessionNurse 22 81Physician 5 19

GenderMale 13 48Female 14 52

Basic educationPrimary school 7 26Secondary school 19 70Other 1 4

Vocational trainingRegistered/specialized nurse 14 52Assistant nurse etc. 8 30MD 1 4MD, Psychiatrist 2 7MD, PhD, Psychiatrist 2 7

Vocational on-the-job training in mentalhealth care

NursesYes 10 45No 12 55

PhysiciansYes 5 100No 0 0


written guidelines on the mode of action incorporatingthe relevant legislation, rules, and criteria for practic-ing seclusion and restraint. However, some nursesstated that they neither had nor needed written guide-lines on the mode of action and that each seclusion andrestraint situation is unique and, therefore, cannot beguided stereotypically with any standard rules ormode of action. Regardless of the opinion on the needfor a written manual or its availability in each unit/hospital, the descriptions of the content of the mode ofaction did not differ (see Table 2).

Participants described the mode of action as follows:using observational skills; therapeutic interaction,which includes de-escalation; offering medication;considering alternatives (offering space, time, coffee);and planning additional manpower (more nurses,

especially males, on the wards with aggressivepatients). The physician is responsible for decisionmaking on seclusion and restraint orders and for theprescription of medications. All participants describedtheir use of tacit knowledge, which is used to makediscretionary judgments and ongoing assessments. Itimproves through experience of managing aggressiveand disturbed patients and can be learned from col-leagues.

Needs for Education

Regarding the educational needs, participants dis-cussed professional and organizational levels, educa-tional methods, and content (see Table 3). Participantsproposed the use of practical education for nurses and

Table 2. Mode of Action in the Treatment of Aggressive and Disturbed Patients

Categories Subcategories Excerpts from nurses’ and physicians’ interviews

Form of modeof action

Written mode ofaction

“There is a written mode of action; guidelines incorporating relevant legislation,rules and criteria related to seclusion, restraint, physical holding . . .”

“Action is based on this written mode of action and on the Mental Health Act.There is also training in the management of aggressive patients and safecare . . .”

Tacit knowledge “There is no written mode of action, action is based on tacit knowledge,practical learning from colleagues . . . In practice medication and seclusion arethe reality . . .”

Content ofmode ofaction

Foresee the situation “. . . mode of action includes foreseeing the situation, observational skills . . .”Interact with the

patient“The working team discusses the situation with the patient and listens to the

patient’s own opinion . . .”Medicate the patient “. . . they give medication . . .”Consider alternatives “Before seclusion and restraint we consider other alternatives: talk with the

patient, lead the patient to her/his room . . .”“The alternatives we use depend on the situation; we start with the lightest and

then go toward the heavier alternatives . . .”Plan manpower “If the patient makes a mess, we need power and many people, especially male

nurses to be able to cope with the situation . . .”Other noteworthy:

division of laborand safety

“The physician is responsible for decision-making on seclusion and restraint, aswell as medication. Male nurses take care of seclusion and restraint situations.Female nurses take care of medication and reporting to physician . . .”

“Safety is very important: physicians do not meet patients alone, there arealways nurses present and we also have alarm systems . . .”



physicians, directors (i.e., head nurses, nursing direc-tors, or medical directors), multidisciplinary teams,and hospitals as a whole. They called for continuingeducation on ethical, clinical, and legal issues, usingpatient case scenarios portraying effective interactionwith aggressive and psychotic patients. Participantsproposed continuing practical on-ward education ashelpful in actual clinical situations. They appreciatedthe use of the knowledge and professional expertise ofexperienced staff to educate and advise other person-nel. They also wanted both individual and teamworkprograms or sessions and regular structured educationand training for all employees.

Needs for Support

Participants’ needs for support fell into two catego-ries: infrastructural and managerial. Infrastructuralsupport comprised staff resources, facilities, andinstructions. Participants identified a need forincreased staff numbers in acute units, a need for saferand smaller units, and a need for a clear mode of action

in aggressive situations. Managerial support includedthe role of occupational health care (i.e., following anepisode of violence), peer support (i.e., debriefing ofthe situations afterward within a peer group as a learn-ing experience), and support (i.e., professional adviceand psychological support following a demandingseclusion/restraint situation) and supervision fromdirectors. Support from peers and directors was per-ceived as very important by both nurses and physi-cians. Participants would like to discuss ethicallydemanding decisions both in the multidisciplinaryteam and with directors.

Discussion

As far as we know, the staff’s subjective needs forseclusion- and restraint-related education in the contextof the actual mode of action and needs for support fornursing practice have not been earlier reported. Theparallel exploration of these facets of seclusion- andrestraint-related know-how made it possible to uncoversome previously unknown phenomena.

Table 3. Needs for Education

Categories Subcategories Excerpts from nurses’ and physicians’ interviews

Professional andorganizationallevel

Nurses and physicians “Practical education for nurses and physicians . . .”Directors “Clinical education and practical experiences for the directors.”Multiprofessional

teams“More emphasis on multidisciplinary teams, nurses and physicians together

and also other professionals . . .”Hospitals “Training programme on how to manage aggressive and disturbed patients

and safe care for all staff in the hospital . . .”Educational

methods andcontent

Theoretical lecture “We need theoretical lectures on the ethical and legal issues . . .”Patient case-based

education“Patient cases are useful examples to study, we can learn how to take care of

the patient, ethical issues, and legal implications can also be learned at thesame time . . .”

Practical on-wardeducation

“Practical on-ward education on how we should take care of the patient inseclusion and restraint situations: what we should observe and educationabout interaction with the psychotic and aggressive patient . . .”

Regularity ofeducation

“Regular systematic training for all employees . . . 1–5 days per year isrealistic . . .”


The parallel exploration of these facets of

seclusion- and restraint-related know-how

made it possible to uncover some

previously unknown phenomena.

It is our contention that some of our findings shouldbe taken into consideration in the planning of futureeducational programs and their implications fornursing practice.

Mode of Action: Form

First, some of the participants articulated a need forwritten seclusion and restraint guidelines, whileothers strongly relied on tacit knowledge and learningfrom colleagues. Furthermore, regardless of thisopinion and of the availability of written guidelines,all participants described a similar content of theirown mode of action that emphasized respect forpatients’ dignity, minimal coercive measures, andusing alternative methods instead of seclusion andrestraint. Independently of treatment guidelines ortacit knowledge, all declared respect for patients’dignity as an important issue in their own currentmode of action. This finding questions the value ofwritten guidelines alone because, without appropriateeducation, they seemed not to yield any additionalbenefit for the staff’s understanding of its own modeof action. Also, there appeared to exist excessive reli-ance on intuition and clinical experience-based tacitknowledge, which obviously requires an evidence-based approach for managing these situations innursing practice (Guidelines International Network,2008; National Institute of Clinical Excellence, 2005)and to bridge the gap between best available evidence

and practice (Bero et al., 1998; Finnish Medical SocietyDuodecim, 2008).

Mode of Action: Content

Second, the participants proclaimed the high ethicalprinciples of their own seclusion and restraint mode ofaction, which was an especially intriguing finding inlight of the notoriously high seclusion and restraintrates in Finland (Salize, Dressing, & Peitz, 2002;Tuohimäki, 2007). Moreover, in seclusion and restraintsituations, the participants appeared to rely heavily onmanpower, especially on male nurses, which pointedtoward paternalistic rather than collaborative practices(Alexander, 2006). Some earlier studies have reportedthat this man power-oriented mode of action may exac-erbate patients’ aggressive behavior (Olofsson, 2005).Hence, it seems that the declared ideal humane modeof action and current seclusion and restraint practicesin these psychiatric hospitals may not always match.Without additional education and training focused onthese particular issues, the common knowledge ofethical and legal requirements regarding seclusionand restraint practices may remain theoretical anddetached from real clinical life.

Needs for Education

The nurses and physicians in our study did indeedacknowledge a need for continuing practical on-wardeducation on seclusion and restraint, which, accordingto earlier reports (Lee et al., 2001), can improve clinicalpractices. Because seclusion and restraint are ethically,clinically, and legally demanding interventions, ourparticipants expressed a need for training based onethically, clinically, and legally problematic case sce-narios, as also did the staff in some earlier studies(Marangos-Frost & Wells, 2000; Olofsson, 2005;Sclafani et al., 2008). Such problem-based educationhas been reported to be effective (Suen et al., 2006).Our interviewees also emphasized a need for trainingin multidisciplinary teams, which, according to the



literature, can indeed reduce the number of seclusionand restraint incidents (Curran, 2007).

Needs for Support

In addition to the needs for education, the staff inour study was aware of a need for support to be ableto practice seclusion and restraint successfully. Thenurses mentioned the importance of occupationalhealth care as a means of managerial support. This isin line with the benefits of such support reportedearlier in nursing practice (Wand & Coulson, 2006).Also, the support and supervision of seclusion andrestraint situations by peers and directors mentionedby our participants may in fact reduce the number ofseclusion and restraint incidents (McCue et al., 2004),improve staff well-being and satisfaction, and, further-more, decrease exhaustion among the staff (Gilbodyet al., 2006; Griffiths, 2001). Education and supportgrossly overlap on the ward level, but their mutualinteraction in nursing practice has not earlier beenexplored. The development of support means in par-allel with the staff’s educational programs could yieldan additional beneficial effect in seclusion andrestraint practices.

Methodological Issues and Future Research

In our study, participation was voluntary, and thedropout rate was low (out of 30 participants invited, 27were present at the focus group interview sessions).Purposive sample, natural setting, and positive groupdynamics and interaction seemed to enhance our datacollection and enable us to gather rich and diverse datapertinent to the research questions. Nevertheless,because we conducted our study in two hospitals (alto-gether six acute wards) in southern Finland, the resultscannot be generalized either nationally or internation-ally, as they cannot be regarded as representative. Thepurpose of this qualitative study was to gain in-depthinformation rather than to produce generalized find-ings. In our study, we split the professions into sepa-

rate focus groups (nurses and physicians), whichfacilitated ventilation of opinions, information, andfeelings within professional groups. However, this didnot allow an exchange of dialog between nurses andphysicians, which might present a limitation. The focusgroup method may, however, lack the sensitivity nec-essary to elucidate differences between the contents ofthe two forms (i.e., written or tacit) of the mode ofaction (Patton, 2007; Robinson, 1999). Therefore, moreresearch is needed on this issue using other researchtechniques and methods. The future research shouldbring together written clinical guidelines, ethical andlegal issues, and the staff’s support aspect.

Conclusions

In the present study, nurses and physiciansdescribed the form (written or tacit) and content of theseclusion- and restraint-related mode of action. Partici-pants recognized a need for on-ward and problem-based education and infrastructural and managerialsupport.

For the first time, the staff’s perceptions of needs foreducation related to seclusion and restraint wereexplored in the context of its own subjectively per-ceived mode of action and needs for support. Thismultifacet approach made it possible to reveal a dis-crepancy between written treatment guidelines andwidely accepted ethical values on the one hand andtheir insufficient manifestation in the current practicesof seclusion and restraint on the other hand. Thispoints toward a need for on-ward and problem-basededucational programs able to fill this gap in nursingpractice. Many nurses relied mostly on tacit know-ledge and learning from colleagues and relied onmanpower—both approaches are sometimes counter-productive and require educational programs with aspecial focus on evidence-based nursing issues. Itremains hypothetical but highly probable that infra-structural and managerial support, complementary toan effective educational program, may have beneficialeffects on seclusion and restraint practices.


We suggest that future educational programs bringtogether written clinical guidelines, education onethical and legal issues, and the aspect of support forstaff. In the future, more emphasis should be put on thedevelopment of seclusion- and restraint-related voca-tional education based on this multifacet approach.

Author contact: [email protected], with a copy to the Editor:[email protected]

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Documents

Nurses' and Physicians' Educational Needs in Seclusion and Restraint Practices