Nurses' and Physicians' Educational Needs in

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

Raija Kontio, RN, MSN, is a Doctoral Student/Director of Nursing, University of Turku, Department of Nursing Science, Turku, Finland, and Hospital District of Helsinki and Uusimaa, Hyvinkää Hospital Region, Kellokoski Hospital, Tuusula, Finland; Maritta Välimäki, RN, PhD, is a Professor/Director of Nursing, University of Turku, Department of Nursing Science, Turku, Finland, and Hospital 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, School of Nursing, Dublin, Ireland; Saija Turpeinen, RN, MSN, is a Head Nurse, Hospital District of Helsinki and Uusimaa, Hyvinkää Hospital Region, Kellokoski Hospital, Tuusula, Finland; Lauri Kuosmanen, RN, MSN, is a Doctoral Student/Project Manager, University of Turku, Department of Nursing Science, Turku, Finland, and Primary Health Care Organisation of City of Vantaa, Vantaa, Finland; and Grigori Joffe, MD, PhD, is Chief of Department of Psychiatry, Hospital District of Helsinki and Uusimaa, Helsinki University Central Hospital, Helsinki, Finland.

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

First received October 29, 2008; Revision received February 26, 2009; Accepted for publication March 1, 2009. 198

Methods of seclusion and restraint have been used

in psychiatric settings in order to restrict the challenging behavior of patients who are expressing psychotic episodes (Niveau, 2004). Sailas and Fenton (2000) have defined seclusion as isolation of patients in a single, locked, unfurnished room where the patient can be monitored by nurses and from which they cannot leave at will, and mechanical restraint as tying a patient onto a bed with bands and belts. Seclusion, restraint, and other compulsory restrictions (e.g., prohibition to leave the ward, temporary confiscation of personal property) present a complex dilemma for the healthcare staff because they call into question patients’ self-determination and human rights, and the legal and ethical responsibilities of the staff (World Health Organization [WHO], 2006). Perspectives in Psychiatric Care Vol. 45, No. 3, July 2009

Furthermore, Sailas and Wahlbeck (2005) have argued that the healthcare staff itself has often perceived seclusion and restraint as beneficial to the patient—an attitude that has changed little in the past few years. On the other hand, staff and patients may have differing perceptions of the effects of seclusion and restraint on patients’ well-being, and this inconsistency may result in a lack of collaboration between staff and patients (Foster, Bowers, & Nijman, 2007). At the same time, seclusion and restraint have been shown to have deleterious physical or psychological effects on both the patient and the staff (Frueh, Cusack, Grubaugh, Sauvageot, & Cousins, 2005). Further, the staff have perceived seclusion and restraint as ethically problematic situations (Lind, Kaltiala-Heino, Suominen, LeinoKilpi, & Välimäki, 2004; Marangos-Frost & Wells, 2000; Sclafani et al., 2008). In general, ethically, high-standard treatment requires professionally skilled and committed staff (Kisely, Campbell, & Preston, 2005; Perraud et al., 2006). In this regard, professional competence in psychiatric care has been declared to be a major challenge in Europe, particularly regarding nursing care for patients experiencing compulsory restrictions (WHO, 2005, 2006). The Council of Europe (2000) also emphasizes the importance of continuing education in this field. Indeed, it has already been shown that education can improve the staff’s well-being and work satisfaction and decrease exhaustion at work (Gilbody et al., 2006; Nolan & Bradley, 2007). Nevertheless, the quality, content, and methods of continuing professional education for qualified nurses working in European psychiatric hospitals are fragmentary (Välimäki, Lahti, Scott, & Chambers, 2008; WHO, 2006). Although there exists a body of literature on educational needs and interventions related with seclusion and restraint (Gaskin, Elsom, & Happell, 2007), thus far, information on the staff’s own point of view has been lacking. This is especially true for knowledge on the type of education and support (e.g., psychological compassion or professional advice) the staff needs to successfully manage these ethically challenging situations (Kisely Perspectives in Psychiatric Care Vol. 45, No. 3, July 2009

et al., 2005). For these educational needs to be identified, the staff’s actual mode of action (seclusion- and restraint-related procedures as usual) should be assessed. We were, however, unable to locate any reports on seclusion- and restraint-focused educational needs explored in parallel with the current mode of action. Moreover, support may substantially affect the seclusion and restraint practices (McCue, Urcuyo, Lilu, Tobias, & Chambers, 2004; Wand & Coulson, 2006), but, to the best of our knowledge, data on its interactions with education have not been published. The purpose of this study was to elicit nurses’ and physicians’ perceptions of their educational needs in the context of their perceived seclusion- and restraintrelated mode of action and their need for support. The aim of the study was to explore what kind of modes of action for aggressive and disturbed patients there are in the unit/hospital and what kind of education and support nurses and physicians would like to have in relation to the management of aggressive and disturbed patients. The study was a part of the European Commission-funded research and development project (Leonardo da Vinci; FI-06-B-F-PP-160701) being conducted in six European countries and focusing on nurses’ vocational training in the management of aggressive 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 explore nurses’ and physicians’ perceptions of their educational needs in the context of their perceived seclusionand restraint-related mode of action and their need for support (Burns & Grove, 2005). In healthcare settings, group interaction encourages respondents to explore and clarify individual and shared perspectives (Tong, Sainsbury, & Craig, 2007). Therefore, a qualitative methodology with a focus group interview was selected as a method to elicit information that could 199

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

only surface in the context of communication among nurses and among physicians (Patton, 2007). Focus group methodology employs an interview technique where the prime objective is to obtain accurate data on a limited range of specific issues (Robinson, 1999). In contrast to a survey, where responses are limited, the aim of the focus group method is not to reach a generalized or representative statement of opinions (Patton). The assumption of the focus group methodology is rather that opinions are not always readily available and are open to influence by others in an interactive setting (Robinson). Simple statistics (e.g., mean, percentage, range) were applied for the demographic characteristics of participants to provide the readers with a clear description of the focus groups. The study was carried out on six wards in two psychiatric hospitals in southern Finland on March 22–26, 2007. The wards were included in the study if they were acute closed-hospital wards practicing seclusion and restraint. The data were collected from nurses and physicians working on the study wards during the study period. The inclusion criteria were as follows: registered nurses and physicians, adequate command of Finnish, voluntary participation, and written informed consent to participate in the study. Purposive sampling involved the conscious selection of nurses and physicians whose working experience in psychiatry was at least 1 year, who were working on the study wards during the study period, and who had repeatedly faced aggressive and disturbed patients and practiced seclusion and restraint—common characteristics that enabled the gathering of rich, relevant, and diverse data pertinent to the research question (Burns & Grove, 2005). A pilot study on nurses (n = 13) was carried out on two acute psychiatric wards to test the suitability of focus group interview for the study phenomena, the feasibility of the semistructured interview form, and the definition of the researchers’ role. After the pilot study, one of the three questions and the role of the researchers were revised. The focus group questions were open ended, allowing the respondents to 200

describe in their own words their views on seclusion and restraint. The following basic questions were asked: (a) What kind of mode of action for aggressive and disturbed patients is there in your unit/hospital? (b) What kind of education would you like to have in relation to the management of aggressive and disturbed patients? (c) What kind of support would you like to have in relation to the management of aggressive and disturbed patients? The additional questions asked on the mode of action were as follows: “Do you have any written guidelines for the mode of action in the unit/hospital?” and “Do you have written guidelines/procedures in relation to the management of aggressive and disturbed patients?” The study was approved by the ethical committee and the institutional authorities. After information about the study and their own rights were completed, participants gave their written informed consent. Of the 22 nurses and 8 physicians invited, all 22 nurses and 6 physicians (2 did not attend the interview) were screened and included. One physician only attended the first 30 min of the interview and was therefore excluded from the analysis. The data were collected by four pretrained researchers in a total of four focus groups, three groups of nurses (N = 22) and one group of physicians (N = 5). The professions were split into separate focus groups (nurses and physicians), which facilitated ventilation of opinions, information, and feelings within professional groups. The researchers had to study literature on qualitative methodology (e.g., Burns & Grove, 2005; Tong et al., 2007) prior to a 4-h focus-group interview seminar, during which the methodology was thoroughly discussed. Exercises included two imaginary cases. The practical training was obtained during the pilot study. There were two researchers in each focus group: a moderator, whose role was to create a nonthreatening, supportive atmosphere to encourage the participants to share their views, and a researcher, who managed the tape recorder and, if needed, also asked questions. During the interviews, the moderator summarized responses after each question and thereby verified the accuracy Perspectives in Psychiatric Care Vol. 45, No. 3, July 2009

of obtained information (Tong et al.). Each focus group interview lasted 80–100 (M = 90) min. The focus group interviews were all tape-recorded and transcribed. Data Analysis The data obtained from the focus group interview were analyzed with inductive content analysis, which is a process used for analyzing documents systematically and objectively (Burns & Grove, 2005). The unit of analysis was an utterance, which could be a sentence or part of a sentence consisting of thematic content relevant to the research question (Burns & Grove; Graneheim & Lundman, 2004). First, the transcribed text was read several times after the unit of analysis had been chosen. Second, reduction of the data was carried out by asking a question and picking out phrases answering that question (basic and detailed questions presented earlier). The third phase was coding, where the reduced phrases were given a description according to their thematic content. Fourth, subcategories were developed for these codes, phrased by grouping together those with similar content. Finally, main categories were created by grouping subcategories with similar meaning (Tong et al., 2007). This form of analysis provided coherence and structure for the data, ensuring that the original data were not skewed in any way. The data from nurses and physicians were handled separately, but, because they were mainly similar, the final analysis comprised the whole group (i.e., nurses and physicians together). Two researchers analyzed the same data set independently and thereafter compared and verified the content and categories obtained. In case of discrepancies, consensus was reached 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: Perspectives in Psychiatric Care Vol. 45, No. 3, July 2009

Table 1. Background Information on Nurses and Physicians Background information (N = 27) Profession Nurse Physician Gender Male Female Basic education Primary school Secondary school Other Vocational training Registered/specialized nurse Assistant nurse etc. MD MD, Psychiatrist MD, PhD, Psychiatrist Vocational on-the-job training in mental health care Nurses Yes No Physicians Yes No

n

%

22 5

81 19

13 14

48 52

7 19 1

26 70 4

14 8 1 2 2

52 30 4 7 7

10 12

45 55

5 0

100 0

1–39); 52% were female. A majority had completed upper secondary education. All physicians and 45% of nurses had received vocational in-service training in mental health care (see Table 1). For the nurses, the vocational in-service training included, for example, courses on the nurse–patient relationship, family and group therapy, or management of aggressive patients. Mode of Action in the Treatment of Aggressive and Disturbed Patients The participants discussed the mode of action that guided the practices of seclusion and restraint in the unit/hospital. The discussion showed that physicians and most nurses emphasized the importance of 201


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

Subcategories

Excerpts from nurses’ and physicians’ interviews

Form of mode of action

Written mode of action

“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 safe care . . .” “There is no written mode of action, action is based on tacit knowledge, practical learning from colleagues . . . In practice medication and seclusion are the reality . . .” “. . . mode of action includes foreseeing the situation, observational skills . . .” “The working team discusses the situation with the patient and listens to the patient’s own opinion . . .” “. . . they give medication . . .” “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 . . .” “If the patient makes a mess, we need power and many people, especially male nurses to be able to cope with the situation . . .” “The physician is responsible for decision-making on seclusion and restraint, as well 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 are always nurses present and we also have alarm systems . . .”

Tacit knowledge Content of mode of action

Foresee the situation Interact with the patient Medicate the patient Consider alternatives

Plan manpower Other noteworthy: division of labor and safety

written guidelines on the mode of action incorporating the relevant legislation, rules, and criteria for practicing seclusion and restraint. However, some nurses stated that they neither had nor needed written guidelines on the mode of action and that each seclusion and restraint situation is unique and, therefore, cannot be guided stereotypically with any standard rules or mode of action. Regardless of the opinion on the need for a written manual or its availability in each unit/ hospital, the descriptions of the content of the mode of action 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, 202

especially males, on the wards with aggressive patients). The physician is responsible for decision making on seclusion and restraint orders and for the prescription of medications. All participants described their use of tacit knowledge, which is used to make discretionary judgments and ongoing assessments. It improves through experience of managing aggressive and disturbed patients and can be learned from colleagues. Needs for Education Regarding the educational needs, participants discussed professional and organizational levels, educational methods, and content (see Table 3). Participants proposed the use of practical education for nurses and Perspectives in Psychiatric Care Vol. 45, No. 3, July 2009

Table 3. Needs for Education Categories

Subcategories

Excerpts from nurses’ and physicians’ interviews

Professional and organizational level

Nurses and physicians Directors Multiprofessional teams Hospitals

Educational methods and content

Theoretical lecture Patient case-based education

“Practical education for nurses and physicians . . .” “Clinical education and practical experiences for the directors.” “More emphasis on multidisciplinary teams, nurses and physicians together and also other professionals . . .” “Training programme on how to manage aggressive and disturbed patients and safe care for all staff in the hospital . . .” “We need theoretical lectures on the ethical and legal issues . . .” “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 the same time . . .” “Practical on-ward education on how we should take care of the patient in seclusion and restraint situations: what we should observe and education about interaction with the psychotic and aggressive patient . . .” “Regular systematic training for all employees . . . 1–5 days per year is realistic . . .”

Practical on-ward education Regularity of education

physicians, directors (i.e., head nurses, nursing directors, or medical directors), multidisciplinary teams, and hospitals as a whole. They called for continuing education on ethical, clinical, and legal issues, using patient case scenarios portraying effective interaction with aggressive and psychotic patients. Participants proposed continuing practical on-ward education as helpful in actual clinical situations. They appreciated the use of the knowledge and professional expertise of experienced staff to educate and advise other personnel. They also wanted both individual and teamwork programs or sessions and regular structured education and training for all employees.

in aggressive situations. Managerial support included the role of occupational health care (i.e., following an episode of violence), peer support (i.e., debriefing of the situations afterward within a peer group as a learning experience), and support (i.e., professional advice and psychological support following a demanding seclusion/restraint situation) and supervision from directors. Support from peers and directors was perceived as very important by both nurses and physicians. Participants would like to discuss ethically demanding decisions both in the multidisciplinary team and with directors. Discussion

Needs for Support Participants’ needs for support fell into two categories: infrastructural and managerial. Infrastructural support comprised staff resources, facilities, and instructions. Participants identified a need for increased staff numbers in acute units, a need for safer and smaller units, and a need for a clear mode of action Perspectives in Psychiatric Care Vol. 45, No. 3, July 2009

As far as we know, the staff’s subjective needs for seclusion- and restraint-related education in the context of the actual mode of action and needs for support for nursing practice have not been earlier reported. The parallel exploration of these facets of seclusion- and restraint-related know-how made it possible to uncover some previously unknown phenomena. 203


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 should be taken into consideration in the planning of future educational programs and their implications for nursing practice. Mode of Action: Form First, some of the participants articulated a need for written seclusion and restraint guidelines, while others strongly relied on tacit knowledge and learning from colleagues. Furthermore, regardless of this opinion and of the availability of written guidelines, all participants described a similar content of their own mode of action that emphasized respect for patients’ dignity, minimal coercive measures, and using alternative methods instead of seclusion and restraint. Independently of treatment guidelines or tacit knowledge, all declared respect for patients’ dignity as an important issue in their own current mode of action. This finding questions the value of written guidelines alone because, without appropriate education, they seemed not to yield any additional benefit for the staff’s understanding of its own mode of action. Also, there appeared to exist excessive reliance on intuition and clinical experience-based tacit knowledge, which obviously requires an evidencebased approach for managing these situations in nursing practice (Guidelines International Network, 2008; National Institute of Clinical Excellence, 2005) and to bridge the gap between best available evidence 204

and practice (Bero et al., 1998; Finnish Medical Society Duodecim, 2008). Mode of Action: Content Second, the participants proclaimed the high ethical principles of their own seclusion and restraint mode of action, which was an especially intriguing finding in light of the notoriously high seclusion and restraint rates in Finland (Salize, Dressing, & Peitz, 2002; Tuohimäki, 2007). Moreover, in seclusion and restraint situations, the participants appeared to rely heavily on manpower, especially on male nurses, which pointed toward paternalistic rather than collaborative practices (Alexander, 2006). Some earlier studies have reported that this man power-oriented mode of action may exacerbate patients’ aggressive behavior (Olofsson, 2005). Hence, it seems that the declared ideal humane mode of action and current seclusion and restraint practices in these psychiatric hospitals may not always match. Without additional education and training focused on these particular issues, the common knowledge of ethical and legal requirements regarding seclusion and restraint practices may remain theoretical and detached from real clinical life. Needs for Education The nurses and physicians in our study did indeed acknowledge a need for continuing practical on-ward education on seclusion and restraint, which, according to earlier reports (Lee et al., 2001), can improve clinical practices. Because seclusion and restraint are ethically, clinically, and legally demanding interventions, our participants expressed a need for training based on ethically, clinically, and legally problematic case scenarios, as also did the staff in some earlier studies (Marangos-Frost & Wells, 2000; Olofsson, 2005; Sclafani et al., 2008). Such problem-based education has been reported to be effective (Suen et al., 2006). Our interviewees also emphasized a need for training in multidisciplinary teams, which, according to the Perspectives in Psychiatric Care Vol. 45, No. 3, July 2009

literature, can indeed reduce the number of seclusion and restraint incidents (Curran, 2007). Needs for Support In addition to the needs for education, the staff in our study was aware of a need for support to be able to practice seclusion and restraint successfully. The nurses mentioned the importance of occupational health care as a means of managerial support. This is in line with the benefits of such support reported earlier in nursing practice (Wand & Coulson, 2006). Also, the support and supervision of seclusion and restraint situations by peers and directors mentioned by our participants may in fact reduce the number of seclusion and restraint incidents (McCue et al., 2004), improve staff well-being and satisfaction, and, furthermore, decrease exhaustion among the staff (Gilbody et al., 2006; Griffiths, 2001). Education and support grossly overlap on the ward level, but their mutual interaction in nursing practice has not earlier been explored. The development of support means in parallel with the staff’s educational programs could yield an additional beneficial effect in seclusion and restraint practices. Methodological Issues and Future Research In our study, participation was voluntary, and the dropout rate was low (out of 30 participants invited, 27 were present at the focus group interview sessions). Purposive sample, natural setting, and positive group dynamics and interaction seemed to enhance our data collection and enable us to gather rich and diverse data pertinent to the research questions. Nevertheless, because we conducted our study in two hospitals (altogether six acute wards) in southern Finland, the results cannot be generalized either nationally or internationally, as they cannot be regarded as representative. The purpose of this qualitative study was to gain in-depth information rather than to produce generalized findings. In our study, we split the professions into sepaPerspectives in Psychiatric Care Vol. 45, No. 3, July 2009

rate focus groups (nurses and physicians), which facilitated ventilation of opinions, information, and feelings within professional groups. However, this did not allow an exchange of dialog between nurses and physicians, which might present a limitation. The focus group method may, however, lack the sensitivity necessary to elucidate differences between the contents of the two forms (i.e., written or tacit) of the mode of action (Patton, 2007; Robinson, 1999). Therefore, more research is needed on this issue using other research techniques and methods. The future research should bring together written clinical guidelines, ethical and legal issues, and the staff’s support aspect. Conclusions In the present study, nurses and physicians described the form (written or tacit) and content of the seclusion- and restraint-related mode of action. Participants recognized a need for on-ward and problembased education and infrastructural and managerial support. For the first time, the staff’s perceptions of needs for education related to seclusion and restraint were explored in the context of its own subjectively perceived mode of action and needs for support. This multifacet approach made it possible to reveal a discrepancy between written treatment guidelines and widely accepted ethical values on the one hand and their insufficient manifestation in the current practices of seclusion and restraint on the other hand. This points toward a need for on-ward and problem-based educational programs able to fill this gap in nursing practice. Many nurses relied mostly on tacit knowledge and learning from colleagues and relied on manpower—both approaches are sometimes counterproductive and require educational programs with a special focus on evidence-based nursing issues. It remains hypothetical but highly probable that infrastructural and managerial support, complementary to an effective educational program, may have beneficial effects on seclusion and restraint practices. 205


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