A narrative of recovery in forensic hospitals.

AIM: Concerns about the applicability of recovery orientation to forensic care have surfaced due to the traditionally restrictive practices associated with forensic institutions. We interviewed 19 experts-by-experience and 18 professionals working with them across five Finnish forensic hospitals and one out-patient clinic to describe how they define recovery in forensic. METHODS: We utilized semi-structured, one-on-one interviews and then analyzed the collected data using structural narrative analysis. Our points of interest were the plots of the recovery stories and the ways in which various factors affected recovery. We also investigated whether staff and experts-by-experience had different perceptions of recovery in forensic psychiatry, and whether recovery-oriented practices were present in these accounts. RESULTS: A wider mutual narrative with a chronological plot was identified, and recovery-oriented practices and goals were found with a special emphasis on offending. Insight into mental illness, motivation for self-care, trust in therapeutic relationships, and gaining possibilities to proceed in care were found to promote recovery, whereas insufficient understanding of the illness, a closed environment, lack of trust, and substance abuse hindered the recovery process. Both the professionals and experts felt that the most prominent goal of recovery is integration into society. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The views of the interviewed experts-by-experience and professionals regarding recovery were rather univocal. Forensic psychiatric services in Finland were found to demonstrate recovery-oriented features, which can be promoted further by involving experts-by-experience in different assignments. The results also highlight that the families of patients should become more active partners in care. IMPACT AND IMPLICATIONS STATEMENT: Recovery in forensic psychiatric hospitals can be perceived as a process towards a new role in society. To reach this goal the forensic patients need support from staff, peers, and family. We found numerous factors which enable and hinder the recovery process, and which should be considered during forensic care.

Use of coercion prevention tools in Finnish psychiatric wards.

Inpatient violence is a widespread problem in psychiatric wards and has often serious consequences. Literature indicates that de-escalation techniques are the recommended first-line intervention for managing violence, are widely used to reduce it, and restrictive practices in mental health settings. However, these techniques and models are not used at the optimum frequency and/or important factors are limiting their use and effectiveness. We aimed to determine what kind of de-escalation methods are used to reduce violence and coercion in Finnish psychiatric hospitals. Descriptive qualitative research using semi-structured questionnaires and Framework Analysis was used. The results of the study are reported in quantitative terms. A survey of psychiatric wards (N = 65) in Finland's hospital districts (n = 16) was conducted in the Autumn of 2019 to find out which de-escalation models are used. Finnish psychiatric wards use both the Safewards and Six Core Strategies models to reduce violence and the use of restrictive practices. Half of the hospitals used interventions and strategies from both models. Violence preventive methods are widely used in mental health settings in Finland. These interventions and models cover the organization, leadership, and patient perspectives to improve safety and decrease coercion actions in psychiatric wards.

Psychiatric nursing managers' attitudes towards containment methods in psychiatric inpatient care.

AIMS: This research was conducted to examine psychiatric nursing managers' attitudes towards containment methods. BACKGROUND: Nursing management is regarded as a key issue in the reduction of coercion and containment. However, there has been little research on managers' attitudes towards containment methods. METHODS: This descriptive, cross-sectional study utilized a survey design. Finnish inpatient psychiatric nursing managers (n = 90) completed the Attitudes to Containment Measures Questionnaire (ACMQ). The results were described with statistics, and the associations between attitudes and background variables were analysed using parametric tests. RESULTS: Psychiatric nursing managers had the most negative attitude towards net bed and mechanical restraint, and the most positive attitudes towards as necessary medication and intermittent observation. A few associations were discovered between attitudes and background variables such as gender and number of employees. CONCLUSIONS: In general, Finnish psychiatric nursing managers' attitudes towards containment methods seem to be quite negative, but more research is needed. IMPLICATIONS FOR NURSING MANAGEMENT: This study provides fresh and unique data on the attitudes of psychiatric nursing managers towards containment methods. Managers' attitudes are important because of their ability to encourage investment in coercion reduction by nursing staff.

Violence Factors and Debriefing in Psychiatric Inpatient Care: A Review.

The aim of the current review was to identify, analyze, and synthesize the available research on violence factors in psychiatric care and the potential of debriefing to reduce the incidence of violence necessitating coercive measures. A two-part electronic search was conducted using multiple databases. Part 1 focused on reviews and meta-analyses relating to violence factors published between 2007 and 2017. Part 2 focused on articles on debriefing published after 2000. Two hundred ninety-five articles on violence factors and debriefing were identified, from which 39 publications were selected for detailed analysis. Results indicate that patient characteristics, management, staff approaches, and the ward environment are influencers that may trigger violent incidents. Several violence factors in psychiatric care have been identified. Nursing communication, leadership, and debriefing are among the most effective ways of reducing violence in psychiatric care. [Journal of Psychosocial Nursing and Mental Health Services, 58(5), 39-49.].

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.

Forensic Psychiatric Patients' Experiences of Personal Recovery: A Wilsonian Concept Analysis.

ABSTRACT: Psychiatric patients' recovery processes have been studied rather extensively, and a relatively clear consensus on what recovery is already exists. We examined whether the personal recovery of forensic psychiatric patients varies from this definition. We conducted a concept analysis to assess the personal recovery of patients in forensic psychiatric hospitals based on 21 articles and then evaluated how our results compared with existing definitions on psychiatric and forensic recovery. On the basis of this comparison, we concluded that the personal recovery of forensic psychiatric patients does differ from that of other psychiatric patients. The recovery process of forensic psychiatric patients can be described through five themes: personal development and autonomy, social inclusion and normality, redemption and overcoming, future orientation and hope, and advancing process. The burden of a psychiatric disorder causes similar challenges, yet a criminal history and long hospitalization periods are distinctive issues for forensic patients, both of which can lead to severe alienation from society and deterioration of skills needed in life outside an institution. The results suggest that processing the criminal offense should be part of the care; furthermore, institutions should support forensic psychiatric patients in their reintegration into society and personal development. Identifying special recovery challenges can be useful when designing effective care and promoting the recovery of forensic patients. Thus, our results suggest that certain features of forensic psychiatric patients' recovery should be considered when planning their psychiatric care.

Patients' Perceptions of Safety and Debriefing in Forensic Mental Health Care in Finland.

BACKGROUND: Safety is of paramount importance to patients and staff in forensic mental health hospitals. Previous research has focused on organizational and nurses' perceptions of safety and violence in psychiatric wards. However, little is known about how patients view their safety. This study aimed to describe how patient debriefing can improve safety. METHODS: Qualitative research using thematic analysis was used. Data were collected by semistructured interviews and debriefing forms. Inpatient interviews ( n = 45) were conducted between June and July 2018, with debriefing forms ( n = 376) collected retrospectively. RESULTS: Forensic inpatient responses were divided into two main categories: psychological and physical security. Psychological safety included care culture and patient-related themes. Responses on care culture highlighted weaknesses in nurse-patient communication, whereas patient-related themes related to respondents' descriptions of the challenges posed by mental illness. Physical safety related to both the environment and patient-related themes, with various restrictions and environmental distractions seen by respondents as negatively affecting patient safety. CONCLUSIONS: Patients who participated in the study felt that care culture, especially communication with nurses, most significantly impacted their safety. Forensic hospitals should consider patients' perceptions of their care while systematically gathering information through debriefing, as these practices can contribute to the development of a safer care environment. The next step will be clarifying how changes in nursing practices and the care environment can be used to prevent violence in psychiatric wards.

Factors Affecting Treatment Regress and Progress in Forensic Psychiatry: A Thematic Analysis.

International variability and shifting trends in forensic psychiatry lead to gaps in national service provision and needs for service development. This study explores these needs through the subjective narratives of those involved in Finnish forensic services, either as forensic psychiatric patients, their parents, or service providers. Data was gathered by means of thematic interview and subjected to thematic analysis. Three main themes emerged: (1) pre-treatment challenges, (2) institutional/treatment-related concerns about therapeutic security and (3) adapting and recovery. The research highlights the need to develop forensic psychiatric services at three levels. First, it calls for increased risk awareness and risk assessment skills at the general psychiatric level. Second, it emphasizes the need for increased therapeutic engagement throughout the rehabilitative process. Third, it calls for structured and meaningful post-discharge aftercare. At all three levels, gradated security-aware standardization and patient triage in forensic services would help to develop and maintain an intact care pathway. This would decrease offending, marginalization, and suffering. Only then can we begin to meet the requirements of the WHO European Mental Health Action Plan. These findings can contribute to the development of international, standardized treatment models for clinical forensic psychiatric practices.

A Bayesian network model to identify the associations between the use of seclusion in psychiatric care and nursing managers' attitudes towards containment methods.

WHAT IS KNOWN ON THE SUBJECT: Seclusion is used frequently in psychiatric care, despite its potential adverse effects. Several programmes aiming to reduce the use of seclusion identify leadership and management as key strategies-however, studies concerning leaders and managers are missing. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE: Nursing managers' negative attitudes towards seclusion are associated with less use of the measure, and nursing managers' higher age is associated with increased use of seclusion. WHAT ARE THE IMPLICATIONS FOR PRACTICE: Nursing managers should be encouraged to guide their staff to reduce the use of seclusion. The negative influences of seclusion and the potential of alternative measures should be highlighted in the education and training of psychiatric nursing managers. ABSTRACT: Introduction The use of seclusion in psychiatric care should be reduced. The relationship between nursing management or nursing managers' attitudes and the use of seclusion has not been investigated. Aim To describe the associations between the use of seclusion and psychiatric nursing managers' attitudes to containment methods. Method Register data concerning the use of seclusion in Finnish psychiatric care in 2017 were collected. The Attitudes to Containment Measures Questionnaire was used to illustrate psychiatric nursing managers' attitudes to containment methods. An Augmented Naive Bayes analysis was used to investigate the relationships of the use of seclusion and attitudes. Results Nursing managers' age and their attitudes towards containment methods were related to the use of seclusion. Especially nursing managers' negative perceptions of seclusion were associated with less use of seclusion, and seclusion was used more often on wards with nursing managers who were older than the average. Conclusion Nursing managers' negative attitudes towards seclusion have a potential impact on the use of seclusion, which might even result in a reduction in its use in psychiatric inpatient setting. Implications for practice The results suggest that nursing managers should be encouraged to guide their staff to decrease the use of seclusion.

Psychiatric nursing staffs' attitudes towards the use of containment methods in psychiatric inpatient care: An integrative review.

One of the international objectives in psychiatric care is reducing the use of coercion. Containment methods are meant to keep patients safe, yet usually include coercion. Nurses play a key role in deciding whether or not containment should be used and, as such, their attitudes towards containment can significantly impact the extent to which these methods are applied. The aim of this integrative review was to identify, analyse, and synthesize the available research on psychiatric nursing staffs' attitudes towards containment methods in inpatient psychiatric care. An electronic search was conducted using the CINAHL, Scopus, and PsycINFO databases. In addition, the citations of identified studies were screened for relevant research. A total of 24 relevant papers published between 2002 and 2017 were selected for further analysis. These studies revealed variation in nursing staffs' attitudes towards the use of containment methods. The use of containment methods seems to be widely accepted and nurses reported rarely considering alternative measures. It appears that attitudes towards containment have continuously become more negative, although the change has not been very pronounced. The concept of attitude was only defined in two studies. Thus, future research should strive to clarify this concept, as a generally accepted definition for attitude within nursing research and the utilization of all dimensions of this concept are both essential to the nursing field. Currently, it would be important to focus on changing attitudes among psychiatric nursing staff to reduce the use of containment methods; this calls for more research on nursing staffs' attitudes.

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.

Patient participation in pro re nata medication in psychiatric inpatient settings: An integrative review.

Pro re nata (PRN) medication is widely used and studied in psychiatric care, but our knowledge about patient participation in its administration is fragmented. The aim of this integrative review was to describe and synthesize previous knowledge of patient participation in PRN in psychiatric inpatient settings. We conducted both electronic and manual searches, using the CINAHL, Scopus, PsycINFO, and PubMed databases, and eight scientific journals. Searches were limited to the English language, to the years 2006-2016, and to selected papers using inclusion, exclusion, and quality criteria. We identified 16 relevant papers, and these showed that patient participation included patient-related starting points, including the patients' willingness to participate and their knowledge of the medication. The patients' participation in PRN practices was demonstrated by the opportunity to request PRN and to refuse any PRN that was offered. Patient participation was shown to be linked to certain situations where PRN was recommended. The role that the professionals played in patient participation included interacting with patients, providing counselling and alternatives for PRN. Our results also revealed that coercion was used administering PRN. The existing literature exposed challenges that need to be addressed if patient participation in the use of PRN medication is to be effectively achieved in psychiatric inpatient settings. Equal partnerships between patients, nurses, and physicians are an essential part of this process, and further research into PRN medication is urgently needed, particularly studies that focus on patients' experiences.

The Therapeutic Approach to a Patient's Criminal Offense in a Forensic Mental Health Nurse-Patient Relationship-The Nurses' Perspectives.

PURPOSE: The purpose of this study is to describe the therapeutic approach to a patient's criminal offense in a forensic mental health nurse-patient relationship from the nurse's perspective. DESIGN AND METHODS: Eight nurses in a Finnish forensic psychiatric hospital were interviewed, and the resultant research material was analyzed by inductive content analysis. FINDINGS: The results revealed the process of the therapeutic approach to a patient's offense, which comprises numerous steps and various phases. PRACTICE IMPLICATIONS: For the nurse, the process of working through the offense can be divided into stages in which an attempt is made to respond to the patient's behavior and interaction in a manner that leads to working through the criminal act.

Seasonal variation of hospital violence, seclusion and restraint in a forensic psychiatric hospital.

Several epidemiological studies have reported seasonal patterns in both violent and self-destructive behaviour. However, a few studies on hospital violence have found contradictory results. The aim of this study was to investigate whether there was any seasonal variation of violence in a forensic psychiatric hospital providing care for persons suffering from psychotic disorders and violent or self-destructive behaviour. Seasonal variation of the prevalence of seclusion and restraint was also investigated. Reports of violent incidents and seclusion and restraint statistics from between 2007 and 2012 were examined with Poisson regression analysis. There was significant variation in the prevalence of seclusion and restraint between months (p<0.001), and between seasons (p<0.001). Monthly prevalence of seclusion and restraint was the lowest in January compared to other months. In comparison, the prevalence of seclusion and restraint was lower in winter than in other seasons. In a hospital with persons suffering from psychotic disorders, no significant variation of violence or self-destructive behaviour was found, similarly as in the society. By contrast, the prevalence of seclusion and restraint showed marked seasonality. Variation in the prevalence of seclusion and restraint was not consistent with the variance in violence, which implies that the use of coercive measures is related to seasonal variation among staff.

De-escalation techniques used, and reasons for seclusion and restraint, in a forensic psychiatric hospital.

In Finland, the Mental Health Act determines the legal basis for seclusion and restraint. Restrictive measures are implemented to manage challenging situations and should be used as a last resort in psychiatric inpatient care. In the present study, we examined the reasons for seclusion and restraint, as well as whether any de-escalation techniques were used to help patients calm down. Seclusion and restraint files from a 4-year period (1 June 2009-31 May 2013) were retrospectively investigated and analysed by content analysis. Descriptive statistics were calculated. A total of 144 episodes of seclusion and restraint were included to analyse the reasons for seclusion and restraint, and 113 episodes were analysed to examine unsuccessful de-escalation techniques. The most commonly-used techniques were one-to-one interaction with a patient (n = 74, 65.5% of n = 113) and administration of extra medication (n = 37, 32.7% of n = 113). The reasons for seclusion and restraint were threatening harmful behaviour (n = 51, 35.4% of n = 144), direct harmful behaviour (n = 43, 29.9%), indirect harmful behaviour (n = 42, 29.1%), and other behaviours (n = 8, 5.6%). In general, the same de-escalation techniques were used with most patients. Most episodes of seclusion or restraint were due to threats of violence or direct violence. Individual means of self-regulation and patient guidance on these techniques are needed. Additionally, staff should be educated on a diverse range of de-escalation techniques. Future studies should focus on examining de-escalation techniques for the prevention of seclusion.

Cluster-randomized controlled trial of reducing seclusion and restraint in secured care of men with schizophrenia.

OBJECTIVE: This randomized controlled trial studied whether seclusion and restraint could be prevented in the psychiatric care of persons with schizophrenia without an increase of violence. METHODS: Over the course of a year, 13 wards of a secured national psychiatric hospital in Finland received information about seclusion and restraint prevention. Four high-security wards (N=88 beds) for men with psychotic illness were then stratified by coercion rates and randomly assigned to two equal groups. In the intervention wards, staff, patients, and doctors were trained for six months in applying six core strategies to prevent seclusion-restraint; six months of supervised intervention followed. Poisson's regression analyses compared monthly incidence rate ratios (IRRs) of coercion and violence (per 100 patient-days). RESULTS: The proportion of patient-days with seclusion, restraint, or room observation declined from 30% to 15% for intervention wards (IRR=.88, 95% confidence interval [CI]=.86-.90, p<.001) versus from 25% to 19% for control wards (IRR=.97, CI=.93-1.01, p=.056). Seclusion-restraint time decreased from 110 to 56 hours per 100 patient-days for intervention wards (IRR=.85, CI=.78-.92, p<.001) but increased from 133 to 150 hours for control wards (IRR=1.09, CI=.94-1.25, p=.24). Incidence of violence decreased from 1.1% to .4% for the intervention wards and from .1% to .0% for control wards. Between-groups differences were significant for seclusion-restraint-observation days (p=.001) and seclusion-restraint time (p=.001) but not for violence (p=.91). CONCLUSIONS: Seclusion and restraint were prevented without an increase of violence in wards for men with schizophrenia and violent behavior. A similar reduction may also be feasible under less extreme circumstances.