Seclusion and Restraint in Psychiatry: Patients' Experiences and Practical Suggestions on How to Improve Practices and Use Alternatives

Seclusion and Restraint in Psychiatry: Patients’ Experiencesand Practical Suggestions on How to Improve Practices andUse Alternativesppc_301 16..24

Raija Kontio, RN, MSN, Grigori Joffe, MD, PhD, Hanna Putkonen, MD, PhD, Lauri Kuosmanen, RN, PhD,Kimmo Hane, RN, Matti Holi, MD, PhD, and Maritta Välimäki, RN, PhD

Raija Kontio, RN, MSN, is a Doctoral Student and Assistant Chief, Department of Psychiatry, University of Turku, Department of Nursing Science, Turku,Finland, and Hospital District of Helsinki and Uusimaa, Hyvinkää Hospital Region, Kellokoski Hospital, Tuusula, Finland; Grigori Joffe, MD, PhD, is thePsychiatrist-in-Chief, Hospital District of Helsinki and Uusimaa, Helsinki University Central Hospital, Helsinki, Finland; Hanna Putkonen, MD, PhD, is aSenior Researcher, Vanha Vaasa Hospital, Vaasa, Finland; Lauri Kuosmanen, RN, PhD, is a Project Manager, University of Turku, Department of NursingScience, Turku, Finland, and Primary Health Care Organisation of City of Vantaa, Vantaa, Finland; Kimmo Hane, RN, is a Masters of Science NursingStudent and Head Nurse, University of Turku, Department of Nursing Science, Turku, Finland, and Hospital District of Helsinki and Uusimaa, HyvinkääHospital Region, Kellokoski Hospital, Tuusula, Finland; Matti Holi, MD, PhD, is the Medical Director, Hospital District of Helsinki and Uusimaa, HelsinkiUniversity Central Hospital/Peijas, Vantaa, Finland; and Maritta Välimäki, RN, PhD, is Professor and Director of Nursing, University of Turku, Departmentof Nursing Science, Turku, Finland, and Hospital District of Southwest Finland, Turku, Finland.

Search terms:Alternative method, inductive content analysis,psychiatric inpatient, psychiatry, restraint,seclusion

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

First Received March 17, 2010; Final Revisionreceived October 15, 2010; Accepted forpublication November 9, 2010.

doi: 10.1111/j.1744-6163.2010.00301.x

PURPOSE: This study explored psychiatric inpatients’ experiences of, and theirsuggestions for, improvement of seclusion/restraint, and alternatives to their use inFinland.METHODS: The data were collected by focused interviews (n = 30) and were ana-lyzed with inductive content analysis.RESULTS: Patients’ perspectives received insufficient attention during seclusion/restraint processes. Improvements (e.g., humane treatment) and alternatives (e.g.,empathetic patient–staff interaction) to seclusion/restraint, as suggested by thepatients, focused on essential parts of nursing practice but have not been largelyadopted.PRACTICE IMPLICATIONS: Patients’ basic needs have to be met, and patient–staffinteraction has to also continue during seclusion/restraint. Providing patientswith meaningful activities, planning beforehand, documenting the patients’ wishes,and making patient–staff agreements reduce the need for restrictions and offeralternatives for seclusion/restraint. Service users must be involved in all practicaldevelopment.

Patient restrictions, e.g., seclusion/restraint, are widely usedin psychiatric hospitals to control challenging behavior inpatients experiencing psychosis (Whittington, Bowers,Nolan, Simpson, & Lindsay, 2009). The acute, and diagnosti-cally the most disturbed, patients are at the highest risk ofbeing secluded and restrained (Happell & Koehn, 2010;Keski-Valkama et al., 2009). Violent behavior or threateningviolence is a commonly accepted indication for the use ofseclusion/restraint (Whittington et al., 2009). Keski-Valkamaet al. (2009) have reported that psychotic behavior is the mostfrequent reason for using coercive measures, even withoutany signs of potential violence, meaning that clinical practicedeviates from the theoretical and legal ground established forcoercive measures. Often, seclusion/restraint are used tocontrol agitation or disorientation too (Keski-Valkama et al.,

2009). Seclusion/restraint are fraught with risks of variousadverse effects, from patients’ deaths to deleterious physicaland psychological effects on both the patient and the staff(Happell & Harrow, 2010; Sailas & Fenton, 2000). In addition,evidence is still lacking regarding their effectiveness in reduc-ing patients’ aggressive behavior (Wright, 2003) or alleviatingserious mental illnesses (Sailas & Fenton, 2000). If seclusion/restraint have to be used, the decision on, and supervision of,the seclusion/restraint procedure by a physician is mandatoryin most Western countries (Muraliharan & Fenton, 2006).Furthermore, seclusion/restraint must be applied in mutualunderstanding between the patient and the staff, and canbe used only when unavoidable, as safely as possible, andwith respect for the patient’s dignity (European Charter ofPatients’ Rights, 2002).

Perspectives in Psychiatric Care ISSN 0031-5990

16 Perspectives in Psychiatric Care 48 (2012) 16–24 © 2011 Wiley Periodicals, Inc.

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In general, psychiatric inpatients tend to be satisfied withtheir care (Hansson,1989;Howard,El-Mallakh,Kay Rayens,&Clark,2003;Müller,Schlösser,Kapp-Steen,Schanz,& Benkert,2002), but patient restrictions used in the management ofaggression and violent behavior (e.g.,seclusion/restraint) mayundermine this satisfaction (Kuosmanen, Hätönen, Jyrkinen,Katajisto, & Välimäki, 2006) as well as treatment adherence(Jenkins, Bennett, Lancaster, O’Donoghue, & Carillo, 2002).Patients’ experiences of seclusion/restraint are mainly nega-tive, harmful, or traumatic (Frueh et al., 2005). Many patientsdo not know the reason why they are placed in seclusion/restraint (Meehan, Bergen, & Fjeldsoe, 2004) and have experi-enced seclusion/restraint as a punishment (Holmes, Kennedy,& Perron, 2004; Keski-Valkama, Koivisto, Eronen, & Kaltiala-Heino, 2010) or as a violation of their autonomy (Hoekstra,Lendemeijer, & Jansen, 2004). Seclusion/restraint-relatednegative emotions often mentioned by patients are anger,helplessness, powerlessness, confusion, loneliness, desolation,and humiliation (Hoekstra et al., 2004). Negative feelingsbecause of perceived lack of interaction with the staff before,during, and after seclusion/restraint are common (Keski-Valkama et al., 2010; Meehan, Vermeer, & Windsor, 2000).However, there are also positive experiences such as a feeling ofsafety or security; some patients see seclusion/restraint as apart of the treatment of their aggressive and violent behavior(Kjellin et al., 2004; Kuosmanen, Hätönen, Malkavaara,Kylmä, & Välimäki, 2007). Because of these contradictoryfindings, it is essential to be aware of individual patients’ per-ceptions and suggestions regarding seclusion/restraint use.

According to earlier studies, patients’ suggestions regard-ing the improvement of seclusion/restraint practices havebeen related to poor interaction with staff, few activities,compulsory medication, and dismal environment (Keski-Valkama et al., 2010; Kuosmanen et al., 2006; Meehan et al.,2000). Patients have expressed a need for more interactionwith nurses and physicians and wanted nurses to respect theirautonomy as much as possible in the process of seclusion/restraint (Olofsson & Nordberg, 2001). Patients have alsoprovided practical suggestions on how to improve the use ofcoercive measures, for example, a possibility to use toiletfacilities and take care of their hygiene, more comfortable bedand bedclothes, smoking provisions, more therapeutic fur-nishing, alarm bell, and ordinary clothing (Keski-Valkamaet al., 2010). It has been suggested that nursing staff shouldsupport patients’ autonomy and, when feasible, let themmake their own decisions, at least in ostensibly minor matterssuch as deciding which clothes to wear, what to eat or drink(Hoekstra et al., 2004; Kuosmanen et al, 2007), or when to goto the toilet or shower (Keski-Valkama et al., 2010). Patientswanted the staff to talk to them and to show genuine interestduring seclusion/restraint. Moreover, patients expressed aneed to discuss the seclusion/restraint event and feelingsafterward (Keski-Valkama et al., 2010; Ryan & Happell,

2009). To ensure high-quality patient-centered psychiatricservices, patients’ experiences and practical suggestions onthe improvement of seclusion/restraint practices and alterna-tives are essential.

Mental healthcare staff has proposed alternatives toseclusion/restraint such as treatment plan improvements,increased staff-to-patient ratios, psychiatric emergencyresponse teams, pharmacological interventions, treatingpatients as active participants in seclusion/restraint interven-tions, and changing the therapeutic environment (Foster,Bowers, & Nijman, 2007). However, the implementation ofthese alternative methods has been apparently insufficient(Gaskin, Elsom, & Happell, 2007). Also, patients have beenasked about their own proposals for alternative methods, butthese data are scarce (Keski-Valkama et al., 2010; Meehanet al., 2000). Patients themselves have suggested less restric-tive alternatives to seclusion/restraint (e.g., one-to-one verbalintervention followed by medication, constant observation,use of the psychiatric intensive care unit, a “time out”program, an opportunity to negotiate with staff [Meehanet al., 2000]), activities, relaxing music, and better explana-tion of ward rules (Keski-Valkama et al., 2010).

In recent years, patients have been increasingly encouragedto take a more active role in the planning and delivery ofhealth care (Council of Europe, 2000). In psychiatry, too, anumber of measures have been undertaken to strengthen theposition of patients (European Commission, 2005). Further-more, the importance of the patient’s perspective and serviceuser involvement in the development of inpatient aggressionmanagement programs has been recognized (Ministry ofSocial Affairs and Health, 2009). In Finland, however, despiteall these efforts, statistics still fail to show a consistent declinein the use of seclusion/restraint (Keski-Valkama et al., 2007).Therefore, it is intriguing to learn what patients’ suggestionstoday might be after these developments have been carriedout in psychiatry.

To understand the present situation in Finland and todelineate future directions (e.g., in educational programs), weexplored in parallel (a) psychiatric inpatients’ experiences ofseclusion/restraint, (b) their suggestions for improvements inseclusion/restraint practices, and (c) alternatives to seclusion/restraint in psychiatry. This study is a part of an internationalEuropean Commission-funded (Leonardo da Vinci; FI-06-B-F-PP-160701) research project on nurses’ vocational trainingin the management of aggressive and disturbed psychiatricinpatients in six European countries.

Methods

Data Collection

A descriptive qualitative approach with open-ended focusedinterview questions was used to explore patients’ individual

Seclusion and Restraint in Psychiatry: Patients’ Experiences and Practical Suggestions on How to Improve Practices and Use Alternatives

17Perspectives in Psychiatric Care 48 (2012) 16–24 © 2011 Wiley Periodicals, Inc.

experiences of seclusion/restraint and their perceptionsregarding the improvement of seclusion/restraint practicesand alternatives to seclusion/restraint on acute psychiatricwards. Qualitative research methods are appropriate whenexploring social phenomena as perceived by the individualsthemselves (Tong, Sainsbury, & Craig, 2007). The study pro-tocol was approved by the Ethics Committee of the HospitalDistrict of Helsinki and Uusimaa (HUS 13.3.2007, §50).The permission for data collection was obtained from theorganizations’ authorities (HUS, Hyvinkää Hospital Region19.4.2007, §136, and HUS, HUCH, 23.4.2007, §158).

Patients were informed of the purpose of the study andassured that participation or refusal to participate would notaffect their care.

The focused interview questions were open-ended, allow-ing participants to describe their experiences, views, and sug-gestions on seclusion/restraint in their own words. The aimwas to promote a relationship of trust and confidence to makethe persons interviewed feel free to say what they wishwithout needing to be afraid that the interviews would affecttheir care (Tong et al., 2007). The following main questionswere asked: (a) Can you describe your latest seclusion/restraint experience, what was it like? (b) What kind of sug-gestions do you have on how to reduce the use and improvepractices of seclusion/restraint? (c) What kind of alternativeswould you prefer instead of seclusion/restraint? The addi-tional questions asked were as follows: “What happenedbefore, during, and after seclusion/restraint?” and “Can youdescribe how to improve the seclusion/restraint practices?”“According to your experience, was there something thatcould be done differently, and how?” “Do you think thatseclusion/restraint is necessary on the wards (when, why/whynot)?”

Four researchers of nursing, with professional back-grounds in psychiatric nursing and training, conductedpatient interviews. To capture acute and recent experiences,the patients were interviewed in the study wards 2–7 daysafter seclusion/restraint. Clinical assessment of the patient’sability to be interviewed without risk of harm was performedby a physician and a nurse prior to enrolment. The durationof the interviews conducted ranged from 11 to 60 minutes(M = 25). Interviews were tape-recorded with patients’ per-mission and transcribed. For five patients who did not givetheir permission for tape-recording, careful notes were made.The demographic characteristics of the patients were col-lected from the patient documents and the data on seclusion/restraint incidents were derived from the hospitals’ seclusion/restraint database.

Participants

The study was conducted on six acute closed wards in twopsychiatric hospitals in Southern Finland from May 12 to

October 31, 2007. Each ward had 18–20 beds and 18–23nurses (all qualified), one head nurse, one or two physicians,and one secretary. In addition, the ward personnel included asocial worker, a psychologist, and an occupational therapistshared with other wards. Nurse/bed ratio was 1.0:1.2—figures typical for acute inpatient wards in Finland (Hätönen,Kuosmanen, Koivunen, & Välimäki, 2010). During the studyperiod, there were a total of 789 patients in the study wards.Patient inclusion criteria were: being secluded/restrainedduring the study period, 18–65 years old, able to speakFinnish, willing to participate in the study, and gave informedconsent. The exclusion criteria were: inability to reasonablycommunicate with the study personnel as assessed by ownnurse and physician in charge. All nurses and physicians werewell informed about the inclusion criteria and they had anopportunity to contact the researcher if there was any confu-sion. In uncertain cases, the physician had to discuss the issueof his/her patient’s participation with a senior physician. Ofthe 120 patients who were secluded/restrained during thestudy period, 46 patients did not meet the inclusion criteria(inability to reasonably communicate with the researcherbecause of poor clinical condition, n = 19; age out of range, n =8; insufficient command of Finnish, n = 8; interviewed beforein other study ward, n = 5; other/unclear reason, n = 6). Of theremaining 74 patients, 16 did not volunteer informed consentand 27 were not offered participation because of inattentionof the personnel, mostly explained by the summer vacationperiod and a high prevalence of temporary staff. Thus, 31patients were finally interviewed. Later on, one patient wasexcluded from the analyses because of a protocol violation(interview conducted 1 day after seclusion instead of 2–7days, as required by the protocol). To sum, altogether 30 inter-views were analyzed.

Patients’ mean age was 41 years (range 20–64 years); 63%were male. The most common diagnosis was schizophrenia(60%) and the most common reason for seclusion/restraintwas harm to others (30%; see Table 1). Average (range) andmedian length of seclusion/restraint was 46 (4–190) and 41hours, respectively.

Data Analysis

The data were analyzed by inductive qualitative contentanalysis, which is a process used for the systematic and objec-tive analysis of documents. First, the interviews were tran-scribed verbatim. Second, the transcriptions of the interviewswere read through several times to form a general picture ofthe material as a whole. The unit of analysis was an utterance,which could be a sentence, or part of a sentence, consisting ofthematic content relevant to the research question. Third,reduction of the data was done by picking out and underlin-ing phrases answering the research question. In the fourthphase, data was coded by labeling reduced phrases with a



description according to thematic content that could be seento characterize the phrases. Fifth, subcategories were thenformed for these coded phrases by grouping together thosewith similar content.Any outstanding discrepancies concern-ing subcategories were resolved. Finally, the set of main cat-egories was established by grouping together subcategorieswith similar meaning (Burns & Grove, 2005).

The quality of the data, that is, the availability of compre-hensive information incorporating all important aspects ofthe interview, was ensured by carefully reading the transcriptsand returning repeatedly to the original data. Furthermore, toovercome the possible effects of the researchers’ subjectiveperceptions, two researchers analyzed the same data set inde-pendently and thereafter compared and verified the contentand categories obtained (Tong et al., 2007).

Results

Patients’ Experiences of Seclusion/Restraint

Patients experienced their seclusion/restraint as a longitudi-nal process starting before the seclusion/restraint, continuingthrough the seclusion/restraint as such, and ending after theseclusion/restraint.

Patients’ experiences before seclusion/restraint refer to thetime before they were put inside the seclusion/restraint room.Patients’ experiences were categorized into two groups: lackof information and way of being treated.

Patients reported mainly that they did not get enoughinformation about their situation, treatment and plans, whatwould happen next, and the reason for seclusion/restraint.This is illustrated in the following examples:

. . . I didn’t understand why they put me into the seclusionroom and I never got information on this. The staff wasreluctant to provide information on why and how long,what next . . . (R2). . . I wondered why the staff lacked willingness to explainissues concerning my treatment and reasons and plans, Ithink it is their job and duty . . . (R6)

Patients were mainly dissatisfied with the way the stafftreated them, how they took care of them, or how theyspoke to them.

. . . Six male nurses put me in the seclusion room before Isaw the physician. I talked with the physician and I sat onthe floor and we didn’t have chairs to sit on. It washumiliating for me . . . (R6). . . I resisted the restraint but they put me onto the bedwith bands and belts, my hands and legs were turned byforce. They used physical strength and force and harshwords . . . (R8). . . Nurses on the ward were professional and polite butnurses in the seclusion room were harsh andunfriendly . . . (R19)

Patients’ experiences during seclusion/restraint refer to thetime the patient was inside the seclusion/restraint room.Patients’ experiences were categorized into four groups:feelings during seclusion/restraint, problems in the care ofbasic needs, lack of activity, and problems in patient–staffcommunication.

Patients described different feelings inside the seclusion/restraint room. Patients felt anger, fear, loneliness, and safetywhen being secluded/restrained.

. . . I felt fear and anger, especially toward those whoput me into the seclusion room. Nurses and physiciansused power and authority over patients. I didn’t knowwhere I was and how long it lasted, it was terrible . . .(R29). . . I thought I was in heaven, feeling much better when Iwas restrained. I did not have nightmares, I was safe . . .(R5)

Patients described problems related to their basic needs,such as washing, toileting, eating, or drinking. The treat-ment facilities did not allow patients to maintain their basicneeds.

. . . I was dirty, I sweated all the time. They washed my haironce a week and I didn’t have a chance to brush my teeth. Iwas thirsty and I peed into the floor-drain . . . (R29). . . I kicked the door a long time so that they couldunderstand my need to get to the toilet. Once I relievedmyself on the porridge plate and put two sandwiches on itto prevent the smell . . . (R2)

Table 1. Characteristics of Patients (N = 30) and theirSeclusion/Restraint Data

n %

GenderFemale 11 37Male 19 63

DiagnosisSchizophrenia 18 60.0Psychotic mood disorder 7 23.3Drug-related psychosis 4 13.4Other psychosis 1 3.3

Reasons for seclusion/restraintHarming others 9 30.1Harming self 7 23.3Endangering other patients’ safety 7 23.3Endangering own safety 7 23.3

Number of seclusion/restraintSeclusion 24 80.1Restraint 2 6.6Seclusion and restraint 4 13.3



Patients reported that they lacked meaningful activitieswhile secluded/restrained, such as reading a book or maga-zine, listening to music, or having some physical exercise.

. . . I did not have anything to do in the seclusion/restraintroom, it was a long time, boring, distressing . . . (R2). . . I shouted and hacked the wall in the seclusion room. Istrangled myself in front of the monitor and four mencame and restrained me . . . (R22). . . I felt restraint was a safe and quiet place to rest andsleep when there was nothing to do or no stimuli . . .(R23)

Patients had mainly negative experiences, but they also hadpositive experiences of communication with the staff duringseclusion/restraint.

. . . I only wanted the real presence of a human being, withnurses and physicians, more communication, humantouch . . . (R24). . . A nurse sat beside me during the whole restraint buthe didn’t say anything, only read the magazine . . . (R7)

Patients’ experiences after seclusion/restraint refer to thetime after leaving the seclusion/restraint room. Patients’experiences were categorized into two groups: outcomes ofseclusion/restraint and opportunity for debriefing.

Outcomes of seclusion/restraint refer to the effects of thisintervention on the patient. After seclusion/restraint, patientsdescribed the outcomes as mainly negative, but there werealso positive experiences.

. . . It was like shock treatment, punishment anddeprivation of liberty, nothing good in it . . . (R2). . . My seclusion experience was much better and morehumane than my restraint experience. It was part of mycare . . . (R25)

The opportunity for debriefing refers to situations andinterventions where patients had the opportunity to discussthe seclusion/restraint situation and the reasons for this inter-vention and the effects of seclusion/restraint on them.

. . . They told me how aggressive and unpredictable I wasbefore seclusion. I understood that this was the onlyalternative and a part of my treatment . . . (R11). . . There was no chance to talk about my experience . . .(R6)

Patients’ Suggestions Regarding the Improvement ofSeclusion/Restraint Practices

The improvement of seclusion/restraint practices concernspatients’ expectations regarding the elements and interven-tions they would like to receive if they need seclusion/restraint as a part of their treatment. Improvement of

seclusion/restraint practices was categorized into fivegroups: humane treatment, external evaluators, up-to-dateinformation, written agreements, and a patient-friendlyenvironment.

Patients reported that they hoped to receive humane andprofessional treatment and interaction with the nurses andphysicians, even during seclusion/restraint. Respectful atten-tion meant being valued as an equal human being instead ofan aggressive and harmful patient in the seclusion/restraintroom. Patients gave critical and mainly negative feedbackrelated to the staff’s treatment and interaction duringseclusion/restraint. They therefore proposed an externalevaluator (e.g., ombudsman, the hospital chaplain) withwhom they wanted to talk about their seclusion/restraintexperience.

. . . I hope that I am a human being in a psychiatrichospital and in the seclusion room too. I want polite,humane behaviour from the staff . . . (R3). . . The staff is for patients. I did not like it that two nursesstood indifferently near me in the seclusion room andtalked by themselves . . . (R9). . . I want to talk with an outside evaluator, patientrepresentative (ombudsman, chaplain) about mythoughts and especially after seclusion/restraint . . .(R26)

Patients expected up-to-date information about their con-ditions and treatment plans and especially information aboutwhen and why they needed seclusion/restraint. Most of thepatients stated that they wanted to be active participants intheir care. They wished to see the written treatment plansthemselves and make written agreements on which steps theyshould follow.

. . . I want information on why I have to be restrained andhow long it will last. I did not have any idea about the timeand plans and what was wrong and when to get acigarette . . . (R10). . . I was in the meeting where we planned my treatment. Iwanted to have this treatment plan for myself and I wanteverything on paper. Written papers can help me, becauseI cannot remember the oral plans and talks . . . (R27)

Patients had many tangible proposals related to thepatient-friendly environment in the seclusion/restraintrooms (e.g., how to increase the humanity, comfort, safety,orientation, and individual elements). They proposed thepossibility of going to the toilet, more therapeutic furnish-ings, a window, an alarm-bell, and a clock.

. . . Opportunity to go to the toilet when you are in theseclusion room, now there is a locked door . . . (R2). . . Beautiful colours on the walls and ceiling, cosy roomwith peaceful music, soft chairs . . . (R5)



. . . TV, radio, magazines, boxing-sack, something to do inthis room, now there is nothing . . . (R7)

Patients’ Suggestions on Alternatives to Seclusion/Restraint

The alternatives to seclusion/restraint comprised interven-tions proposed by patients. Alternatives to seclusion/restraintwere categorized into four groups: empathetic patient–staffinteraction, meaningful activities, therapeutic community,and biological treatments.

Patients were mainly dissatisfied with the interaction withthe staff and found this interaction to be the single mostimportant alternative to seclusion/restraint. Patients stressedthe importance of interaction with the nurses and physicians,with more of their time used with the patients on the ward,even through silent presence beside the patient, staff’s empa-thetic listening, attention and understanding, active commu-nication, mindful presence here and now, tactfulness, andhumane reflection on the illness of a person.

. . . I need a human being beside me. I want to talk aboutmy fears with the physician and nurse. I like to have aconnection to them, now they are in a hurry all thetime . . . (R7). . . Discussion with familiar nurses can help and decreasefears and anger. My primary nurse talks kindly and asksme to think about solutions, alternatives . . . (R26). . . It is essential to try to solve the difficult situation bydiscussion instead of using coercion (e.g., seclusionroom) . . . (R4)

In the wards there was nothing to do and the days wereboring. Patients underlined the importance of meaningfulactivities on the ward (e.g., daily activities, making coffee) oroutside (e.g., physical activities, occupational therapies) tobring content to the idle days and life. Patients would expectthe staff to actively encourage them into activities even if theywere tired or feeble.

. . . I need physical activities when I am restless, aboxing-sack on the ward, going out for cycling or walking.Something sensible to do . . . (R6). . . If I just had an access to the coffee machine and got acup of hot coffee, nothing else would be needed . . . (R5)

Patients emphasized the importance of the therapeuticcommunity, safe atmosphere, and cozy environment of theclosed wards where they spent most of their time. The roleof nurses in creating this atmosphere, together with thepatients, was pivotal. A private, peaceful, single room foreach patient would allow for more autonomous and pur-poseful regulation between time spent in the patient com-munity and privacy.

. . . Nurses and patients can together create a safe and cozyatmosphere and community . . . (R19)

. . . A peaceful environment is also important. Asingle-room if possible. After medication I’d rather go tomy own room to sleep than to the seclusion room . . .(R2). . . Quiet, beautiful place to go on the ward, quiet roomwith relaxing music . . . (R15)

Instead of seclusion/restraint, patients would prefer bio-logical treatments, first of all, appropriate medication. Brainmodulation treatments were also mentioned.

. . . Medicine may help me and my nightmares. I hope thatI can get relaxing medicine and then I can go to my ownroom and bed to rest . . . (R7). . . There are new treatments, like electric shock andmagnetic stimulation. Why couldn’t one try these insteadof the ancient ones, like restraint . . . (R13)

Discussion

The study showed that patients experienced seclusion/restraint as mainly negative—as they did in the studies byFrueh et al. (2005) and Keski-Valkama et al. (2010). Our find-ings support the earlier ones, that patients’ own perspectivesdid not receive sufficient attention (Holmes et al., 2004;Keski-Valkama et al., 2010). Given the fact that Finland is aWestern democracy with definite seclusion/restraint-relatedlegislation (Amendment to the Mental Health Act, 1423/2001, 2001), professional guidelines and ethical codes for thestaff (ICN, 2006), the finding of unmet basic physical needsduring the seclusion/restraint period was striking. In someseclusion/restraint cases, patients in our data were evendenied access to toilet facilities and had to defecate on thefloor. Although easier access to toilet has been proposed bypatients in earlier studies (Keski-Valkama et al., 2010), suchan extreme grade of violation of basic rights as with ourpatients had not, to the best of our knowledge, been reportedin the literature before.

As in some earlier reports (Hoekstra et al., 2004; Holmeset al., 2004), many of our patients felt that the time spent inseclusion/restraint was long, boring, and distressful becausethey had nothing to do. This contradicted an unambiguousstatement of the European Committee for the Prevention ofTorture and Inhuman or Degrading Treatment or Punish-ment (2009) that in the seclusion/restraint room, patientsshould have some meaningful activities (e.g., magazines,books, television). Although one could argue that a patientcapable of watching television should not even be secluded/restrained; our findings indicate a need for profound changesin the culture and (sometimes intolerable) practices ofseclusion/restraint. For example, the “design” of the seclusionroom has been similar for decades aiming not only to dimin-ish stimuli but in fact deprive patients (Muraliharan &Fenton, 2006). In the study wards, seclusion rooms were



locked rooms with no furniture, only a mattress on the floor.Restraint rooms had a bed with bands and belts and a chairbeside the bed where the nurse could observe the patient.From the rooms there was no free access to the bathroom orthe toilet. Both seclusion and restraint rooms had videomonitoring systems. Because current seclusion/restraintpractices fail to show clinical effectiveness as a treatment foraggressive behavior (Wright, 2003) or serious mental disor-ders (Sailas & Fenton, 2000), it is obviously time to optimizethe seclusion/restraint practices and employ novel interven-tions. As a part of this transformation, a more comfortableand safely furnished environment should be tested in Finnishpsychiatric settings.

As a means to encourage patients to take a more active rolein planning and delivery of health care (Council of Europe,2000), patients’ suggestions on improvements in psychiatriccare should be taken seriously. As in earlier reports (Meehanet al., 2000), the patients in our study expressed negative feel-ings because of a perceived lack of therapeutic interactionwith the staff in the process of seclusion/restraint. To respondto these needs, some clinical measures could be considered.For example, a nurse-in-charge could be appointed for everyseclusion/restraint episode to take care of the communicationwith the patient. This communication should include at leastessential arguments for the use of seclusion/restraint, its esti-mated duration, and expected results. Because of the currentlack of such sufficient interaction with the staff, our patientsproposed this interaction and, in addition, the use of external(i.e., non-staff members) evaluators to discuss theirseclusion/restraint experiences. This proposal of externalevaluators concurs with some earlier studies (Kuosmanenet al., 2007). The national recommendations (Ministry ofSocial Affairs and Health, 2009) also encourage the use ofexternal evaluators, but once again, neither official recom-mendations nor scientific findings seem to be readily imple-mented in nursing practice.

Patients in our study focused on essential parts of nursingpractice (empathetic interaction, meaningful activities,therapeutic community, and biological treatments), but theyproposed only few new concrete alternatives to seclusion/restraint. This stresses the crucial role and responsibility ofmental health professionals, in close collaboration withservice users, in the invention and implementation of newpractical methods to diminish the use of seclusion/restraint.Indeed, this development process seems to be going on inmany countries and institutions (Happell & Harrow, 2010;Happell & Koehn, 2010; Hyde, Fulbrook, Fenton, & Kilshaw,2009; Wynaden et al., 2002). For example, Huckshorn (2004)presented a theoretical and practical basis for prevention ofseclusion/restraint: (a) executive leadership; (b) data as adriver for change; (c) development of workforce; (d) practicaltools and techniques; (e) empowering service user; and (f)post-seclusion/restraint debriefing.

Our study had some limitations. Only two hospitals par-ticipated in the study and only a minority of patients could beenrolled. Firstly, a group of patients (n = 19, 16%) wereassessed by their nurses and physicians as incapable of rea-sonable communication with the researchers because of apoor clinical condition—an exclusion criterion defined apriori by the study protocol in accordance with basic ethicalrequirements. Secondly, there were six patients (5%) who didnot meet inclusion criteria and the reason was unclear andcould not be explored afterward by the researchers. Thirdly, anumber (n = 27, 23%) of patients were not offered participa-tion at all because of inattention of the personnel. Fourthly, aproportion (n = 16, 13%) of patients was unwilling to partici-pate. Eventually, only 31 patients (26% of 120 potential par-ticipants) were interviewed, which could bias our results.Indeed, it is possible that some of the patients were omitted bythe staff on purpose. This could not be rigorously explored.However, this is unlikely because in uncertain cases, a secondopinion was obtained from researchers and senior physicians.Moreover, the purpose of this study was not to provide objec-tive unbiased generalizable data, but rather to obtain qualita-tive in-depth information on patients’ subjective views andneeds regarding seclusion/restraint in psychiatric care byusing focused interviews with open-ended questions andanalyzing the data with inductive content analysis. Thismethod allowed to raise individual experiences and sugges-tions proposed by the patients related with the sensitive andsocial phenomena.

To indicate specific elements of the seclusion/restraintpractices to be improved (e.g., through future educationalprograms), future research should probably explore thepatients’ perspective as mirrored in the contemporaneouslyinvestigated staff perspective. This two-dimensional viewwould likely reveal some aspects of patient restrictions andalternatives to seclusion/restraint that are not salient in dailynursing practice. Moreover, interviewing pooled groups com-prised of patients, nurses, and physicians together could gen-erate additional insights regarding improved nursingpractice. At best, interviewing these groups together maybecome an intervention in itself, but this assumption shouldbe addressed by separate studies.

Implications for Nursing Practice

It seems that in current nursing practice, the seclusion/restraint-related individual needs of the patients still oftenremain unmet, and the service user involvement is insuffi-cient. The occasionally negligent attitudes to patients’ basicneeds were striking, indicating a need for a profound changein the seclusion/restraint culture. Meeting patients’ basicneeds, like access to the toilet and washing facilities duringseclusion/restraint is still not self-evident and remains amajor issue in nursing practice. The process of seclusion/



restraint must start with ensuring first and foremost that thepatients’ basic needs are met. Also, meaningful activities maybe classified as basic needs and should be promoted as a toppreference in seclusion/restraint-related nursing. In addition,more comfortable and safely furnished environments in bothseclusion and restraint rooms should be tested in psychiatricsettings.

Making patients active participants in the continuingprocess of development of ever more patient-centerednursing in psychiatric hospitals cannot be overemphasized.Patient–staff interaction has also to continue duringseclusion/restraint, and it must be both preceded and accom-panied by sharing adequate information. Every patient with anegative seclusion/restraint experience should be given anopportunity to immediately discuss this experience with thestaff and a few days later with both the staff and an externalevaluator. Planning beforehand, writing down the patient’swishes, and making patient–staff agreements in advancemight reduce the need for restrictions and sometimes offeralternative methods for seclusion/restraint—a developmentdesirable from the patients’ point of view.

Not all of the above may be achievable without articulatingthe content and culture of executive leadership, persistentsensitizing of the staff to mindful reflection of patients’ real-time subjective experiences, and encouraging patients to playa more active role in their treatment process. All developmentwork needs to be carried out in working groups with serviceusers as equal members of the team, able to voice theirthoughts and desires.

Acknowledgments

We would like to thank the Hospital District of Helsinki andUusimaa (TK) and the Hyvinkää Hospital Region (EVO) forfunding this study.

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Seclusion and Restraint in Psychiatry: Patients' Experiences and Practical Suggestions on How to Improve Practices and Use Alternatives