The Use of Seclusion and Mechanical Restraint in Psychiatry - A Persistent Challenge over Time

Mielisairaisiin kohdistuvilla pakkotoimenpiteillä, kuten huoneeseen tai lepositeisiin eristämisellä, on pitkä historia. Ne ovat osa myös tämän päivän psykiatriaa. Nykykäsityksen mukaan psykiatrisen sairaalahoidon aikana käytettäviin pakkotoimenpiteisiin pitäisi turvautua ainoastaan viimeisenä keinona silloin, kun se on välttämätöntä potilaan tai muiden turvallisuuden kannalta. Pakkotoimenpiteiden käytön tulisi olla mahdollisimman vähäistä ja selkeästi perusteltua. Vastaako tämä käsitys psykiatrian arkitodellisuutta? Alice Keski-Valkama tarkastelee sosiaalipsykiatrian alaan kuuluvassa väitöskirjatutkimuksessaan huone-eristyksen ja lepositeiden käyttöä suomalaisessa psykiatriassa 1990 luvun alusta tähän päivään. Tutkimuksessa selvitetään, missä määrin näitä pakkotoimenpiteitä käytetään osana psykiatrista sairaalahoitoa, miksi pakkotoimenpiteitä käytetään, ketä pakkotoimenpiteiden kohteena olevat potilaat ovat ja millainen kokemus pakkotoimenpiteen kohteena oleminen on. Lisäksi tutkimuksessa annetaan suuntaa pakkotoimenpiteiden käytön kansainväliseen vertailuun. Valtakunnallinen kyselylomake- ja rekisteritutkimus toteutettiin 1990 2004 välisenä aikana. Tutkimuksen kohteena olivat maamme kaikki psykiatriset sairaalat. Haastattelututkimukseen osallistui yli sata eristettyä potilasta kahdesta oikeuspsykiatrisesta sairaalasta sekä kahden sairaanhoitopiirin psykiatrisesta sairaalasta Suomessa. Kasvainvälisessä pakkotoimenpiteitä käsittelevässä osatutkimuksessa oli mukana kaksitoista maata Suomi mukaan lukien. Kansainvälistä kehitystä mukaillen maassamme on kuluneen kahden vuosikymmenen aikana kiinnitetty lainsäädännöllisesti huomiota sekä potilaan asemaan ja oikeuksiin terveydenhuollossa, että tahdosta riippumattomien toimenpiteiden edellytyksiin psykiatriassa. Tutkimus kuitenkin osoitti, että lainsäädäntömuutokset eivät yksinään riittäneet olennaisesti vähentämään pakkotoimenpiteiden käyttöä 15 vuoden tarkastelujaksolla. Huone-eristyksen ja lepositeiden käyttömäärissä ja valinnassa havaittiin alueellisia eroja. Huone-eristysten kesto kasvoi kolminkertaiseksi. Tavallisin pakkotoimenpiteiden syy oli kiihtynyt ja sekava käyttäytyminen ilman merkkejä toteutuneesta tai uhkaavasta väkivallasta. Pakkotoimenpiteet kohdistuivat pääasiassa kliinisesti kaikkein vaikeimpiin potilaisiin. Haastattelututkimus osoitti, että riippumatta siitä, oliko kyseessä valtion oikeuspsykiatrinen sairaala vai sairaanhoitopiirin psykiatrinen sairaala, eristettynä oleminen oli potilaille kielteinen ja mieleenpainuva kokemus. Ainoa havaittu ero sairaalatyyppien välillä oli se, että oikeuspsykiatrisissa sairaaloissa hoidossa olevat potilaat kokivat eristämisen vielä useammin rangaistukseksi. Eristettyjen potilaiden näkökulmasta tarkasteltuna pakkotoimenpiteiden käytössä oli sekä psykologisia että fyysisiä puutteita. Kansanvälinen vertailu osoitti huomattavia eroja pakkotoimenpiteiden valinnassa ja määrissä. Suomi asettui tässä vertailussa keskivaiheille. Hankkeita pakkotoimenpiteiden käytön rajoittamiseksi on jo meneillään joissakin Euroopan maissa. Tutkimus tukee aiemmin esitettyjä olettamuksia siitä, että syvään juurtuneet käytännöt ja asenteet määrittävät pakkotoimenpiteiden käyttöä ainakin yhtä vahvasti kuin turvallisuusnäkökohdat ja potilaiden oikeudet. Vaikka joissakin tilanteissa pakkotoimenpiteisiin turvautuminen on välttämätöntä, tavoitteena tulisi olla niiden mahdollisimman vähäinen käyttö. Tämä edellyttää yhteisesti hyväksyttyjen toimintatapojen jatkuvaa tarkastelua. Tutkimuksen perusteella erityisesti pakkotoimenpiteiden käytön syihin ja kestoon on kiinnitettävä huomiota. Pakkotoimenpiteen kohteeksi joutuneen potilaan fyysinen ympäristö ja psykologiset tarpeet on huomioitava nykyistä paremmin.Coercive measures, such as seclusion and mechanical restraint, have a long history in dealing with mental illness. Both the ethical and legal frameworks for using coercive measures acknowledge that the use of them is, at times, indispensable, but they should only be considered at the last resort, as a safety measure. In this thesis, the use of coercive measures in psychiatry is studied at the level of international and national statistics as well as at the level of the individual patients. The international meta-analysis of published, unpublished and ongoing research regarding the use of coercive measures (mechanical restraint, seclusion, physical restraint) between 2000 and 2008 comprised databases from twelve countries in and beyond Europe. The Finnish nationwide study regarding the use of seclusion and mechanical restraint was conducted in a specific week in 1990, 1991, 1994, 1998 and 2004. The material was collected from two sources: The Survey Data covered all Finnish psychiatric hospitals, and comprised 671 working-age secluded or mechanically restrained patients. The Register Data covered all hospitalised working-age psychiatric inpatients during the study period (N = 28 064). The interview study was composed of the baseline interviews of 106 secluded patients at the two forensic psychiatric hospitals and at the psychiatric inpatient units of two hospital districts in Finland. A follow-up interview was completed by 83 of the participants. The present study indicates that coercive measures are in general use in Western psychiatry, but the type and the quantity vary considerably across countries. Initiatives to curtail the use of coercive measures already exist in a few European countries. Finland stood at the average point on the preliminary international statistics in the use of seclusion and mechanical restraint. Despite the tendency of official policies towards the least restrictive psychiatric treatment in our country during the last two decades, national statistics of the present study indicate, that legislation solely can not change the use of coercive measures. The risk for being secluded had not changed, while the risk for being mechanically restrained decreased slightly, but not linearly, during this timeframe. Furthermore, the duration of mechanical restraint remained the same, and the duration of seclusion increased even three-fold. A rather well-entrenched establishment of seclusion and mechanical restraint seems to prevail in clinical practice. These measures were used mainly among the most clinically disturbed patients. Patient agitation or disorientation with no accompanying signs of actual or threatening violence was the most frequent clinical indication for the use of these measures. Psychiatric patients equate seclusion with prolonged, negative connotations, independent of the type of hospital where the treatment is administered. The only difference detected between the secluded patients in the forensic psychiatric hospitals and the general psychiatric in-patient units was that the forensic patients even more frequently viewed seclusion as a form of punishment. From the viewpoint of the secluded patients, both psychological and physical conditions under which coercive measures are implemented in everyday clinical practice are deficient. Fundamental human considerations demand that the least intrusive practices be achieved and improved upon in order to reduce the use of coercive measures. This thesis indicates that almost no changes toward the reduced use of seclusion and mechanical restraint have taken place over the years, which confirms previous suggestions that deep-rooted treatment traditions and attitudes at least as much as safety requirements or patients` rights determine the use of coercive measures. The shared intention should be to find the best practices to moderate the use of these measures, or when they are really indicated, how they can be implemented in a more benevolent manner. Special attention should be directed toward duration and indications for seclusion and mechanical restraint. Physical conditions and psychological needs of the secluded or mechanically restrained patient must be more scrupulously taken into account

Carbook: A Platform for Mobile Automotive Services

Wireless mobile technologies have triggered a rapid development of secondary network technologies. One such prominent field of technology is interoperability for consumer devices. This field is mostly based on XML and Web Services and it includes technologies such as Universal Plug-and-Play, open media container formats, open codecs and Rich Internet Application technologies for mobile devices. Automotive field has been relatively slow and conservative in embracing these new Internet technologies. This is about to change as European Union and other substantial players are pressing forward with the safety and environmental technologies in cars. These technologies depend heavily on wireless Internet connectivity. As part of this thesis work, I have played a central role in defining the core concept of a distributed framework for mobile automotive services, Carbook System. I have also outlined the first phase of a shared research environment, Carlab, for these kinds of services. Carlab is used to demonstrate different technologies in accordance to Elektrobit’s vision for the future automotive Internet services. Carbook System will be implemented incrementally jointly with the continuation of the Carlab implementation. In this master of science thesis I have mapped and evaluated the essential technologies and created a preliminary outline for Carbook System and a set of services. The first phase Carlab network topology and emulation of different domains in Carbook System are also drafted in this thesis work

Vaarallisuuden ja väkivaltariskin arvioiminen

Hankkeessa tuotettiin tietoa vaarallisuuden ja väkivaltariskin arvioimisesta. Vaikka vaarallisuudesta edelleen puhutaan, on väkivaltariskin arviointi syrjäyttänyt vaarallisuusarvioinnin arviointimenetelmien kehittymisen myötä. Arviointimenetelmien käyttöä ja niiden luotettavuutta selvitettiin terveydenhuollolle, rikosseuraamusalalle, ennaltaehkäisevän toiminnan alalle sekä tuomioistuimille ja syyttäjille toteutetulla kyselyllä. Toimijoiden mukaan arvion ajankohtaa tulisi tarkastella, lisätä niin käsitteistön kuin arvioiden yhdenmukaisuutta sekä parantaa arvioiden laatua. Elinkautisvangille tehtävä väkivaltariskiarvio otetaan huomioon vangin hakiessa pääsyä ehdonalaiseen vapauteen, mutta arvion painoarvo vapauttamisharkinnassa on epäselvä. Väkivaltariskiarvio johtaa nykyisin aina käytännön mukaan riskinhallintasuunnitelmaan, mikäli riskejä todetaan. Mutta koska riskiarvio tehdään tuomion loppuvaiheessa, jolloin pitkäjänteisiä kuntouttavia suunnitelmia ei ole ehditty laittaa täytäntöön, eikä väkivaltariskiarvioiden loppupäätelmiä ja suosituksia ole hyödynnetty vapauttamissuunnitelmien laatimisessa, on todennäköistä, ettei väkivaltariskiarviota voida pitää interventiona, joka johtaisi väkivaltaan syyllistymisen riskin madaltamiseen.Tämä julkaisu on toteutettu osana valtioneuvoston selvitys- ja tutkimussuunnitelman toimeenpanoa. (tietokayttoon.fi) Julkaisun sisällöstä vastaavat tiedon tuottajat, eikä tekstisisältö välttämättä edusta valtioneuvoston näkemystä

Unidimensionality of the Strengths and Vulnerabilities Scales in the Short-Term Assessment of Risk and Treatability (START)

The Short-Term Assessment of Risk and Treatability (START) is a 20-item structured professional judgment instrument for assessing dynamic risk in mental health services. Much of the START research literature examines the relationship between Strengths and Vulnerabilities sub-scale total scores and various adverse outcomes including violence. This assumes that the two sub-scales have the psychometric property of unidimensionality i.e. all the items cluster together as a measure of a single construct. Such assumed unidimensionality is a necessary condition for any analyses based on scale “total score” and the widespread use of scores summated in this way in research studies may obscure more specific clusters of items within each sub-scale. This multinational study examined START assessments (n = 685) conducted in four forensic services in Scandinavia and the UK using principal component analysis. It was found that all but three Strengths items (Substance Use, Social Support and Material Resources) and all but four Vulnerabilities items (Substance Use, Social Support, Material Resources and Self care) loaded >0.5 on the expected component. This indicates a unidimensional structure underlying the START and provides empirical support from a large multinational sample for the widespread use of summated Strengths and Vulnerabilities scores in forensic psychiatric risk research

Developing a spatially explicit modelling and evaluation framework for integrated carbon sequestration and biodiversity conservation: application in southern Finland

The challenges posed by climate change and biodiversity loss are deeply interconnected. Successful co-managing of these tangled drivers requires innovative methods that can prioritize and target management actions against multiple criteria, while also enabling cost-effective land use planning and impact scenario assessment. This paper synthesises the development and application of an integrated multidisciplinary modelling and evaluation framework for carbon and biodiversity in forest systems. By analysing and spatio-temporally modelling carbon processes and biodiversity elements, we determine an optimal solution for their co-management in the study landscape. We also describe how advanced Earth Observation measurements can be used to enhance mapping and monitoring of biodiversity and ecosystem processes. The scenarios used for the dynamic models were based on official Finnish policy goals for forest management and climate change mitigation. The development and testing of the system were executed in a large region in southern Finland (Kokemäenjoki basin, 27 024 km2) containing highly instrumented LTER (Long-Term Ecosystem Research) stations; these LTER data sources were complemented by fieldwork, remote sensing and national data bases. In the study area, estimated total net emissions were currently 4.2 TgCO2eq a-1, but modelling of forestry measures and anthropogenic emission reductions demonstrated that it would be possible to achieve the stated policy goal of carbon neutrality by low forest harvest intensity. We show how this policy-relevant information can be further utilised for optimal allocation of set-aside forest areas for nature conservation, which would significantly contribute to preserving both biodiversity and carbon values in the region. Biodiversity gain in the area could be increased without a loss of carbon-related benefits.The challenges posed by climate change and biodiversity loss are deeply interconnected. Successful co-managing of these tangled drivers requires innovative methods that can prioritize and target management actions against multiple criteria, while also enabling cost-effective land use planning and impact scenario assessment. This paper synthesises the development and application of an integrated multidisciplinary modelling and evaluation framework for carbon and biodiversity in forest systems. By analysing and spatio-temporally modelling carbon processes and biodiversity elements, we determine an optimal solution for their co-management in the study landscape. We also describe how advanced Earth Observation measurements can be used to enhance mapping and monitoring of biodiversity and ecosystem processes. The scenarios used for the dynamic models were based on official Finnish policy goals for forest management and climate change mitigation. The development and testing of the system were executed in a large region in southern Finland (Kokemäenjoki basin, 27,024 km2) containing highly instrumented LTER (Long-Term Ecosystem Research) stations; these LTER data sources were complemented by fieldwork, remote sensing and national data bases. In the study area, estimated total net emissions were currently 4.2 TgCO2eq a−1, but modelling of forestry measures and anthropogenic emission reductions demonstrated that it would be possible to achieve the stated policy goal of carbon neutrality by low forest harvest intensity. We show how this policy-relevant information can be further utilized for optimal allocation of set-aside forest areas for nature conservation, which would significantly contribute to preserving both biodiversity and carbon values in the region. Biodiversity gain in the area could be increased without a loss of carbon-related benefits.Peer reviewe

Caught between compassion and control: exploring the challenges associated with inpatient adolescent mental healthcare in an independent hospital

Aim. To extend our understanding of how healthcare assistants construct and managedemanding situations in a secure mental health setting and to explore the effects ontheir health and well-being, to provide recommendations for enhanced support.Background. Contemporary literature acknowledges high rates of occupationalstress and burnout among healthcare assistants, suggesting the context in whichthey work places them at elevated risk of physical harm and psychologicaldistress. Yet, there is a deficit of qualitative research exploring the experiences ofhealthcare assistants in adolescent inpatient facilities.Design. An exploratory multi-method qualitative approach was used to collectdata about the challenges faced by healthcare assistants working on secureadolescent mental health wards in an independent hospital during 2014.Method. Fifteen sets of data were collected. Ten participants completed diaryentries and five participants were also interviewed allowing for triangulation.Data were analysed using Interpretive Phenomenological Analysis.Findings. The findings illustrated how inpatient mental healthcare is a unique anddistinctive area of nursing, where disturbing behaviour is often normalized anddetached from the outside world. Healthcare assistants often experienced tensionbetween their personal moral code which orientate them towards empathy andsupport and the emotional detachment and control expected by the organization,contributing to burnout and moral distress.Conclusions. This study yielded insights into mental health nursing andspecifically the phenomenon of moral distress. Given the ever-increasing demandfor healthcare professionals, the effects of moral distress on both the lives ofhealthcare assistants and patient care, merits further study

A Review of Interventions to Reduce Mechanical Restraint and Seclusion among Adult Psychiatric Inpatients

Objective: This review examines nature and effectiveness of interventions to reduce the use of mechanical restraint and seclusion among adult psychiatric inpatients. Method: Electronic searches were conducted to locate post-1960 empirical studies of restraint and seclusion reduction in English. A total of 36 studies were identified, mostly from the USA. Analysis was conducted using a structured data extraction tool. Results: The majority of studies reported reduced levels or mechanical restraint and/or seclusion, but the standard of evidence was poor. There were no randomised trials. Most were retrospective studies of official records before and after the intervention was introduced, with varying follow-up periods. The interventions were diverse, but tended to include one or more of the following: new restraint and/or seclusion policies, staffing changes, staff training, review procedures and crisis management initiatives. The research was unable to address which of these elements was most effective. There was also evidence that some improved outcomes were achieved by substituting restraint or seclusion for each other or for alternatives forms of containment (medication in particular). Nurses’ attitudes, skills and approach to patient care were absent from the literature. Conclusions: Interventions probably can reduce the use of restraint and seclusion, but better designed research is required to demonstrate their effectiveness conclusively. More attention should also be paid to understanding how interventions work, particularly from the perspective of nursing staff. This is essential to the successful implementation of restraint and seclusion interventions across different psychiatric settings and treatment populations

Gender differences in coerced patients with schizophrenia

European Commission (Quality of life and Management of Living Resources Programme, contract number QLG4-CT- 2002-01036), Czech Ministry of Education research grant MSM002160849, and research grants PRVOUK–P26/LF1/4 and PRVOUK–P03/LF1/