Nurses' perceptions of nurse-patient communication in seclusion rooms in psychiatric inpatient care: A focus group study.

WHAT IS KNOWN ON THE SUBJECT?: Communication between nurses and patients is essential in mental health nursing. Lack of communication during seclusion causes dissatisfaction among patients. Coercive practices can cause psychological discomfort for patients and staff members. Research related to nurses' perceptions of nurse-patient communication during seclusion events is scant. In Finland, the use of coercive practices has been high despite efforts to reduce the need for coercive practices through the National Mental Health Policy since 2009. Nurse-patient communication is referred to in the Safewards model as one issue of delivering high-quality care. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Nurses aim to achieve high-quality communication while treating patients in seclusion. Nurses aim to communicate in a way that is more patient-centred. Various issues affect the quality of communication, such as nurses' professional behaviour and patients' state of health. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Improved communication between nurses and patients will support therapeutic relationships and could lead to a better quality of care. Nurses' enhanced communication may promote the use of noncoercive practices more frequently in psychiatric settings. Improving nurses' communication skills may help support the dignity and autonomy of secluded patients, resulting in patient experiences that are more positive in relation to care offered in seclusion. Nurses should be offered opportunities to take part in further training after education to enhance communication skills for demanding care situations. Further research that incorporates the perspectives of patients and those with lived experience of mental health problems is needed. Components of evidence-based Safewards practices, such as using respectful and individual communication (Soft Words), could be relevant when developing nurse-patient communication in seclusion events. ABSTRACT: INTRODUCTION: Communication between nurses and patients is essential in mental health nursing. In coercive situations (e.g. seclusion), the importance of nurse-patient communication is highlighted. However, research related to nurses' perceptions of nurse-patient communication during seclusion is scant. AIM: The aim of this study was to describe nurses' perceptions of nurse-patient communication during patient seclusion and the ways nurse-patient communication can be improved. METHOD: A qualitative study design using focus group interviews was adopted. Thirty-two nurses working in psychiatric wards were recruited to participate. The data were analysed using inductive qualitative content analysis. RESULTS: Nurses aimed to communicate in a patient-centred way in seclusion events, and various issues affected the quality of communication. Nurses recognized several ways to improve communication during seclusion. DISCUSSION: Treating patients in seclusion rooms presents highly demanding care situations for nurses. Seclusion events require nurses to have good communication skills to provide ethically sound care. CONCLUSION: Improved nurse-patient communication may contribute to shorter seclusion times and a higher quality of care. Improving nurses' communication skills may help support the dignity of the secluded patients. Safewards practices, such as respectful communication and recognizing the effect of non-verbal behaviour, could be considered when developing nurse-patient communication in seclusion events. RELEVANCE STATEMENT: This study deepens the understanding of nurse-patient communication during seclusion events from the perspective of nurses. Caring for patients in seclusion presents challenging situations for nurses and demands that they have good communication skills. To enhance their communication skills in seclusion events, nurses require opportunities to take part in further training after education related to communication skills for demanding care situations. Knowing the appropriate ways to interact with individual patients during seclusion can help nurses create and maintain communication with patients. For mental health nursing, nurses' enhanced communication may promote increased use of noncoercive practices in psychiatric settings. For patients, improving nurses' communication skills may help support dignity and autonomy during seclusion and shorten the time spent in seclusion, resulting in a better quality of care and more positive patient experiences related to care offered in seclusion. In this, the perspectives of people with lived experience of mental health problems should be acknowledged. Components of Safewards practices, such as using respectful and individual communication and paying attention to one's non-verbal communication (Soft Words), could be useful when developing nurse-patient communication in seclusion events.

Safety hazards in patient seclusion events in psychiatric care: A video observation study.

WHAT IS KNOWN ON THE SUBJECT?: Coercive measures such as seclusion are used to maintain the safety of patients and others in psychiatric care. The use of coercive measures can lead to harm among patients and staff. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study is the first of its kind to rely on video observation to expose safety hazards in seclusion events that have not been reported previously in the literature. The actions that both patients and staff take during seclusion events can result in various safety hazards. IMPLICATIONS FOR PRACTICE?: Constant monitoring of patients during seclusion is important for identifying safety hazards and intervening to prevent harm. Nursing staff who use seclusion need to be aware of how their actions can contribute to safety hazards and how they can minimize their potential for harm ABSTRACT: Introduction Seclusion is used to maintain safety in psychiatric care. There is still a lack of knowledge on potential safety hazards related to seclusion practices. Aim To identify safety hazards that might jeopardize the safety of patients and staff in seclusion events in psychiatric hospital care. Method A descriptive design with non-participant video observation was used. The data consisted of 36 video recordings, analysed with inductive thematic analysis. Results Safety hazards were related to patient and staff actions. Patient actions included aggressive behaviour, precarious movements, escaping, falling, contamination and preventing visibility. Staff actions included leaving hazardous items in a seclusion room, unsafe administration of medication, unsecured use of restraints and precarious movements and postures. Discussion This is the first observational study to identify safety hazards in seclusion, which may jeopardize the safety of patients and staff. These hazards were related to the actions of patients and staff. Implications for Practice Being better aware of possible safety hazards could help prevent adverse events during patient seclusion events. It is therefore necessary that nursing staff are aware of how their actions might impact their safety and the safety of the patients. Video observation is a useful method for identifying safety hazards. However, its use requires effort to safeguard the privacy and confidentiality of those included in the videos.

Offense-Related Issues in Forensic Psychiatric Treatment: A Thematic Analysis.

Characteristics unique to forensic psychiatric treatment include coming to terms with the offenses committed, the long duration of treatment and the assessment of the risk of repeat offending. This study describes the views of both patients and staff on the significance of the patient's offense as a part of forensic psychiatric rehabilitation. Eight forensic psychiatric patients and eight forensic psychiatric nurses from two forensic psychiatric hospitals in Finland participated in this study. Data were gathered by means of thematic interview and analyzed by means of thematic analysis. The findings suggest that patients and professionals alike concur that ascertaining the factors with a bearing on the offense, and working through the offense and the factors leading up to it, constitute an essential aspect of forensic treatment. This, in turn, has a bearing on the planning and administration of a treatment plan consisting of both medical and psychosocial support and interventions intended to enable patients to live independent, fulfilling lives, thus reducing the likelihood of reoffending. The findings of this study can be used as part of the development of international, standardized treatment models for clinical forensic psychiatric practices.

Forensic Psychiatric Patients' Perspectives on Their Care: A Narrative View.

PURPOSE: The purpose of this study is to describe forensic psychiatric patients' experiences of and perspectives on forensic psychiatric treatment. DESIGN AND METHODS: Eight forensic psychiatric patients were interviewed, and the resultant research material was analyzed by narrative analysis. FINDINGS: Patients' narratives contain different themes telling different things and the personnel need to pay attention to these. PRACTICE IMPLICATIONS: The findings of the present study should direct the forensic psychiatric personnel's attention to the notion that forensic psychiatric patients' experiences of their treatment can improve the quality of patient-centered care and reduce bureaucracy.

The Offense as Perceived by the Parents of Forensic Psychiatric Patients.

This study aims to describe the views of forensic psychiatric patients' parents, and especially how they feel about the patient's offense. The data analyzed was collected by interviews with forensic psychiatric patients' parents and analyzed by inductive content analysis. The findings suggest that the offense committed has a significant effect on the lives of parents of forensic psychiatric patients and in many ways these people felt like a marginalized group even though they were frequently a major resource for their child who had been taken into forensic psychiatric care. The parents of a forensic psychiatric patient have a prominent role in the life of the patient and this role and the parents' coping should also be supported by the forensic psychiatric treatment system.

Forensic psychiatric patients' narratives of their offense.

This study aims to describe forensic psychiatric patients' experiences of their offense and its meaning for their lives, and to increase the understanding of the meaning of the offense in the eyes of the patient. The data analyzed was collected by interviews with forensic psychiatric patients and analyzed by narrative analysis. The findings suggest that forensic psychiatric patients have different types of stories describing the offense and its meaning in their lives. Illness narratives can be utilized therapeutically because they may construct patients' identity, experiences, and their situation as people with an illness seek explanations and meanings for their plight.

Methodological and ethical challenges in studying patients' perceptions of coercion: a systematic mixed studies review.

BACKGROUND: Despite improvements in psychiatric inpatient care, patient restrictions in psychiatric hospitals are still in use. Studying perceptions among patients who have been secluded or physically restrained during their hospital stay is challenging. We sought to review the methodological and ethical challenges in qualitative and quantitative studies aiming to describe patients' perceptions of coercive measures, especially seclusion and physical restraints during their hospital stay. METHODS: Systematic mixed studies review was the study method. Studies reporting patients' perceptions of coercive measures, especially seclusion and physical restraints during hospital stay were included. Methodological issues such as study design, data collection and recruitment process, participants, sampling, patient refusal or non-participation, and ethical issues such as informed consent process, and approval were synthesized systematically. Electronic searches of CINALH, MEDLINE, PsychINFO and The Cochrane Library (1976-2012) were carried out. RESULTS: Out of 846 initial citations, 32 studies were included, 14 qualitative and 18 quantitative studies. A variety of methodological approaches were used, although descriptive and explorative designs were used in most cases. Data were mainly collected in qualitative studies by interviews (n = 13) or in quantitative studies by self-report questionnaires (n = 12). The recruitment process was explained in 59% (n = 19) of the studies. In most cases convenience sampling was used, yet five studies used randomization. Patient's refusal or non-participation was reported in 37% (n = 11) of studies. Of all studies, 56% (n = 18) had reported undergone an ethical review process in an official board or committee. Respondents were informed and consent was requested in 69% studies (n = 22). CONCLUSIONS: The use of different study designs made comparison methodologically challenging. The timing of data collection (considering bias and confounding factors) and the reasons for non-participation of eligible participants are likewise methodological challenges, e.g. recommended flow charts could aid the information. Other challenges identified were the recruitment of large and representative samples. Ethical challenges included requesting participants' informed consent and respecting ethical procedures.

Does experienced seclusion or restraint affect psychiatric patients' subjective quality of life at discharge?

BACKGROUND: In Finland major effort has been invested in reducing the use of coercion in psychiatric treatment, and the goal is to diminish the use of coercion by 40% by 2015. Improving patients' quality of life (QoL) has gained prominence in psychiatric treatment during the past decade. Numerous studies have shown that most secluded or restrained patients (S/R patients) would prefer not to have had this experience. Experience of S/R could affect negatively patients' QoL, but empirical data on this issue are lacking. AIM: The study aimed to explore the effect of experienced S/R on the subjective QoL of psychiatric in-patients. METHOD: This study explored subjective QoL of the S/R patients. At discharge, S/R patients completed the Short Form of the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF). RESULTS: We found that S/R patients' (n = 36) subjective QoL was significantly better than that of non-S/R patients' (n = 228). Most non-S/R patients were diagnosed with mood disorders (mostly depression). Most of S/R patients were diagnosed with schizophrenia, schizotypal and delusional disorders. The mean duration of S/R was 2.3 days, median was one day and mean length of the hospitalization after S/R episode was 2.5 months. CONCLUSION: Our cross-sectional findings suggest that S/R does not considerably influence patients' QoL or that the influence is short-lived. Because baseline QoL was not measured this remains uncertain. There are also many other factors, such as negative mood, which decrease the patients' QoL ratings. These factors may either mask the influence of S/R on QoL or modify the experience of QoL to such an extent that no independent association can be found at the time of discharge.

Secluded and restrained patients' perceptions of their treatment.

Though some empirical and anecdotal accounts can be located in the extant literature, it remains the case that little is known about how secluded/restrained (S/R) patients perceive their overall treatment. The purpose of this study was to explore patients' perceptions of their hospital treatment measured after S/R. The data were collected with a Secluded and Restrained Patients' Perceptions of their Treatment (S/R-PPT) questionnaire from S/R patients aged 18-65 years. Ninety completed questionnaires were analysed. Patients perceived that they received enough attention from staff, and they were able to voice their opinions, but their opinions were not taken into account. Patients denied the necessity and beneficence of S/R. Women and older patients were more critical than men and younger patients regarding the use of restrictions. There were also statistically-significant differences in responses among patients at different hospitals. It is concluded that patients' opinions need more attention in treatment decisions. To achieve this, psychiatric treatment needs genuine dialogue between patients and staff, and individual care should have alternatives and no routine decisions. Therefore, the treatment culture must improve towards involving patients in treatment planning, and giving them a say when S/R is considered.

Secluded/restrained patients' perceptions of their treatment: validity and reliability of a new questionnaire.

AIM: To develop a standardized self-reporting questionnaire to evaluate patients' perceptions of their overall treatment in specific relation to the use of seclusion and/or restraint (SR) measures as part of the treatment program. METHODS: A 17-item self-rating questionnaire was given to 56 patients with experience of SR-related treatment to develop a new scale, the Secluded/Restrained Patients' Perceptions of their Treatment (SR-PPT). Concurrent validity was examined against the Client Satisfaction Questionnaire-8 Japanese Version (CSQ-8J). In addition, Patient burden induced by answering the SR-PPT was evaluated. RESULTS: On factor analysis, two factors named as Cooperation with Staff (nine items) and Perceptions of SR (two items) were derived. Cronbach's coefficient alphas were 0.928 and 0.887, and correlation coefficients against the CSQ-8J were 0.838 and 0.609, respectively. Answering the SR-PPT was found to induce little burden on the patients. CONCLUSION: Adequate internal consistency and concurrent validity of the final version of the SR-PPT, which consists of 11 items, indicate that it is acceptable as a measurement scale. Use of this questionnaire will add the patient's view to the assessment of overall treatment involving SR.

Sample purification improves the analysis of nonviral in vivo gene transfection.

Nonviral gene delivery has gained a lot of interest as a promising approach for gene therapy. Despite intensive studies and much progress the outcome of nonviral vectors has remained significantly weaker than that of viral vectors. A weak transfection efficiency of nonviral gene transfection is still limiting their in vivo use. We have tested the possibility to improve the measurement of transfection efficiency by increasing the sensitivity of analysis with sample purification. The BPVlacZ and CMVlacZ plasmids were transfected by i.v. infusion of the PEI/DNA complexes in the rats. An adenovirus lacZ vector was used as a reference. The transfection efficiency was analysed from the lungs and brain. Tissue samples were minced and homogenized for preparation of crude homogenates and for further purification of crude homogenates with a DEAE anion exchange chromatography. The beta-galactosidase activity was measured using a luminometric assay. The obtained activity of beta-galactosidase was higher in the purified than nonpurified samples and the analysis of transfection efficiency as beta-galactosidase activity was improved more than 1000-fold by the purification of samples from perfused target tissues. An increased sensitivity of analysis by sample preparation may be a useful and inexpensive strategy to detect and estimate a low transfection efficiency or transgene expression often associated with a nonviral in vivo gene delivery.

The role of PEI structure and size in the PEI/liposome-mediated synergism of gene transfection.

Polyethylenimines (PEIs) and cationic liposomes are widely used for nonviral gene delivery. When PEIs have been used alone, the transfection efficiency has been higher for larger or linear than smaller or branched PEIs. We have reported previously that a combination of small PEIs and liposomes results in a potentiation of transfection efficiency in vitro. Here, the role of PEI size and structure in this synergism has been clarified further. Therefore, two structurally different high MW PEIs, i.e. the linear PEI22K and branched PEI25K, were studied in the SMC cells. We found that both linear PEI22K and branched PEI25K resulted in a similar synergism and comparable transfection efficiencies. However, the potentiation for larger PEIs found in the present study was weaker than that for smaller PEIs obtained in our previous studies. In conclusion, our present and previous results demonstrate that the increment of PEI/liposome-mediated gene transfection by different types of PEIs in vitro is a common attribute that is rather associated with their size than the structure. Interestingly, the effect of PEI size seems to be opposite when combined with liposome or given alone, i.e. the small PEIs are more effective when combined and less effective when alone than the larger ones.

Effect of cell-surface glycosaminoglycans on cationic carrier combined with low-MW PEI-mediated gene transfection.

Glycosaminoglycans (GAGs) are negatively charged polysaccharides that are found, e.g. on cell surface. GAGs have been reported to influence gene transfection. We have previously reported that cationic lipid-mediated gene transfection can be improved by combining a small polyethylenimine (PEI) with cationic lipids. In the present study, we examined if GAGs have any effect on the synergism of small PEIs and other cationic carriers. We used wild-type CHO (GAG+) and pgsB-618 cells (GAG-). Transfection efficiency was studied using lacZ and GFP reporter genes. We found that GAGs decreased the overall level of transgene expression in a reagent-dependent manner, but the synergism caused by low-MW PEIs was less affected. There were no major differences between cell lines in cellular uptake or intracellular localization of plasmids when measured with flow cytometry and confocal microscopy, respectively. In conclusion, cell-surface GAGs interfere with transfection efficiency of different cationic reagents, but that is not necessarily related to the synergy of small PEIs and cationic lipids.

Synergism in gene delivery by small PEIs and three different nonviral vectors.

We have reported earlier that a combination of low-molecular weight polyethylenimines (PEIs) with the cationic liposome, Dosper, results in a synergistic increase in the transfection efficiency. Now we have investigated whether this synergism is a general mechanism seen with other transfection reagents as well. Therefore, we have combined the low-molecular weight PEIs (MW 700 and 2000) with Dotap (a monocationic liposome), Lipofectamine (a combination of neutral and polycationic liposome), and Superfect (a dendrimer). The highest synergism was achieved with Lipofectamine and PEIs in the SMC cells, or with Dotap and PEIs in the C6 cells. Superfect did not induce any synergism. The combinations did not cause any changes in DNA condensing ability measured with ethidium bromide exclusions. The proton pump inhibitor, bafilomycin A1, had similar effects in both cell lines. Interestingly, the combination of Dosper (a positive control) and PEI caused the most effective transfection synergism in the presence of serum, although Lipofectamine, with or without PEIs, was a very potent reagent demonstrating the best transfection efficiency in the absence of serum. It is suggested that the PEI/Dosper-mediated synergism in the transfection efficiency may be a general mechanism for liposomal transfection reagents, although the effects can vary depending on cell lines.