The use of patient restrictions (e.g. involuntary admission, seclusion, restraint) is a complex ethical dilemma in psychiatric care. The present study explored nurses’ (n = 22) and physicians’ (n = 5) perceptions of what actually happens when an aggressive behaviour episode occurs on the ward and what alternatives to seclusion and restraint are actually in use as normal standard practice in acute psychiatric care. The data were collected by focus group interviews and analysed by inductive content analysis. The participants believed that the decision-making process for managing patients’ aggressive behaviour contains some in-built ethical dilemmas. They thought that patients’ subjective perspective received little attention. Nevertheless, the staff proposed and appeared to use a number of alternatives to minimize or replace the use of seclusion and restraint. Medical and nursing staff need to be encouraged and taught to: (1) tune in more deeply to reasons for patients’ aggressive behaviour; and (2) use alternatives to seclusion and restraint in order to humanize patient care to a greater extent.

Patient violence against nurses in their work environments is a widespread global concern, particularly in the field of mental health care. A high prevalence of violent events impacts the well-being of nurses and may also impair overall ward climate. However, it has been proposed that nurses’ use limited techniques to prevent patient violence, and, therefore, more comprehensive methods for dealing with patient violence are needed. There is still restricted understanding of the ward climate during the occurrence of a violent event as well as how these incidents could be more effectively prevented. This study aimed to explore nurses’ experiences of violent events in psychiatric wards, give insight into ward climates and examine suggestions for violence prevention. This study employed a descriptive, exploratory design including focus groups (n = 5) and open-ended questions. The participants were registered and enrolled nurses (n = 22) working on three closed psychiatric in-patient wards in one Finnish hospital district. Focus groups were tape-recorded, transcribed and analyzed with inductive content analysis. Nurses’ experiences of violent events included a variety of warning signs and high-risk situations which helped them to predict forthcoming violence. Patient-instigated violent events were described as complicated situations involving both nurses and patients. When the wards were overloaded with work or emotions, or if nurses had become cynical from dealing with such events, well-being of nurses was impaired and nursing care was complicated. Suggestions for violence prevention were identified, and included, for example, more skilled interaction between nurses and patients and an increase in contact between nurses and patients on the ward. This study revealed the complexity of violent events on psychiatric wards as well as the implications of these events on clinical practice development and training, administration and policy. A routine process is needed through which nurses’ experiences and ideas concerning prevention of violent events are acknowledged.

Patient aggression and violence against staff members and other patients are common concerns in psychiatric units. Many structured clinical risk assessment tools have recently been developed. Despite their superiority to unaided clinical judgments, staff has shown ambivalent views towards them. A constant worry of staff is that the results of risk assessments would not be used. The aims of the present study were to investigate what were the interventions applied by the staff of a psychiatric admission ward after a high risk patient had been identified, how frequently these interventions were used and how effective they were. The data were collected in a naturalistic setting during a 6-month period in a Finnish psychiatric admission ward with a total of 331 patients with a mean age of 42.9 years (SD 17.39) suffering mostly from mood, schizophrenia-related and substance use disorders. The total number of treatment days was 2399. The staff assessed the patients daily with the Dynamic Appraisal of Situational Aggression (DASA), which is a structured violence risk assessment considering the upcoming 24 h. The interventions in order to reduce the risk of violence following a high DASA total score (≥4) were collected from the patients’ medical files. Inductive content analysis was used. There were a total of 64 patients with 217 observations of high DASA total score. In 91.2% of cases, at least one intervention aiming to reduce the violence risk was used. Pro re nata (PRN)-medication, seclusion and focused discussions with a nurse were the most frequently used interventions. Non-coercive and non-pharmacological interventions like daily activities associated significantly with the decrease of perceived risk of violence. In most cases, a high score in violence risk assessment led to interventions aiming to reduce the risk. Unfortunately, the most frequently used methods were psychopharmacological or coercive. It is hoped that the findings will encourage the staff to use their imagination when choosing violence risk reducing intervention techniques.

To explore service users' (n = 9) delayed perceptions of and suggestions for improvement of management of aggression/violence in psychiatry. Focus group interviews, inductive content analysis. Participants reported aggression/violence-related negative perceptions (including loneliness, boredom, excessive control, and fear) but also memories of humane and caring personnel. The suggestions included meaningful activities and humane, interactive nursing. Delayed perceptions and proposals resembled the proximate ones. Perceptions may persist for years. Such perceptions and proposals, if taken into account from the beginning of treatment, may prevent negative long-term consequences of witnessed or experienced aggression/violence. Humane, interactive nursing models should be studied and disseminated.

Background : The management of psychiatric inpatients exhibiting severely disturbed and aggressive behaviour is an important educational topic. Well structured, IT-based educational programmes (eLearning) often ensure quality and may make training more affordable and accessible. Aims : The aim of this study was to explore the impact of an eLearning course for personnel on the rates and duration of seclusion and mechanical restraint among psychiatric inpatients. Methods : In a cluster-randomized intervention trial, the nursing personnel on 10 wards were randomly assigned to eLearning (intervention) or training-as-usual (control) groups. The eLearning course comprised six modules with specific topics (legal and ethical issues, behaviour-related factors, therapeutic relationship and self-awareness, teamwork and integrating knowledge with practice) and specific learning methods. The rates (incidents per 1000 occupied bed days) and durations of the coercion incidents were examined before and after the course. Results : A total of 1283 coercion incidents (1143 seclusions [89%] and 140 incidents involving the use of mechanical restraints [11%]) were recorded on the study wards during the data collection period. On the intervention wards, there were no statistically significant changes in the rates of seclusion and mechanical restraint. However, the duration of incidents involving mechanical restraints shortened from 36.0 to 4.0 h (median) (P < 0.001). No statistically significant changes occurred on the control wards. Conclusions : After our eLearning course, the duration of incidents involving the use of mechanical restraints decreased. However, more studies are needed to ensure that the content of the course focuses on the most important factors associated with the seclusion-related elements. The eLearning course deserves further development and further studies. The duration of coercion incidents merits attention in future research.